Defensive qi (qi defensivum, weiqi): its modern use according to the treatise on cold damage (Shanghan lun) and the doctrine of warm diseases (morbi temperati, wenbing).

Weiqi, defensive qi (qi defensivum, weiqi) is deployed throughout the external surfaces (extima, biao) and flows through the channels. This defensive qi (qi defensivum, weiqi) protects the body from external heteropathies (xie). It also regulates body temperature, sweating, circadian rhythm and sensory perceptions. In the system of six main channels in the Treatise on Cold Damage (Shanghan lun) a disorder of the major yang (yang maior, taiyang) is regarded as an illness of the defensive qi (qi defensivum, weiqi). In the four-levels model of Warm Diseases (morbi temperati, wenbing) a disturbance of this defensive layer (qi defensivum, weiqi) is related to the early stage of fever caused by warm pathogens (calor heteropathies, rexie) as, for example, in the case of influenza, pneumonia, Covid-19, etc. This article cites passages from the Treatise on Cold Damage (Shanghan lun) and from the doctrine of Warm Diseases (morbi temperati, wenbing) for the treatment with Chinese phytotherapy;it also describes the corresponding acupuncture points and moxibustion treatments and how the theory of defensive qi (qi defensivum, weiqi) is to be applied in the treatment of long Covid, sleep disorders, depression and anxiety, sweating and bi-syndrome.Copyright © 2023, The Author(s) under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.

Thermoregulation and subjective thermal perception of N95 respirator users: Influence of significant workloads

Working under a significant metabolic rate while wearing an N95 mask increased the heat stress that users of protective clothing experienced. This study investigated in a climatic chamber preset at 25 degrees C and a relative humidity of 65% the changes in thermoregulation and thermal perception of 13 men and 12 women when performing exercises involving different metabolic consumption for 60 min first without wearing an N95 mask for 30 min and then donning a mask. The physiological parameters include the metabolic rate, tympanic temperature, heart rate, skin temperature, skin moisture, and transepidermal water loss (TEWL). Thermal perceptions, including thermal sensation, humidity sensation, thermal comfort, and thermal acceptance were surveyed. The results show that both N95 mask use and exercising contributed to vigorous thermoregulation, particularly in women. The tympanic temperature was between 35.5 degrees C and 36.5 degrees C during the experiment for both sexes. Skin temperature during the exercise with or without donning a mask was not influenced by the change in workload, indicating a balance in heat exchange between the body and ambient air. Skin moisture increased by 58.91% and 49.99% when the users of masks performed exercises involving moderate and very high metabolic rates, respectively, compared to levels when a mask was not worn. The TEWL of women and men when wearing a mask and jogging increased by 16.35% and 14.89%, respectively, compared to when not wearing the mask. These results suggests a potential thermal stress from using N95 masks and working in a warm environment when the users are not acclimatized.

Chapter 4 - Heat exposure and child health

Although children's heat-related mortality risk is lower than elderly's, children are physiologically susceptible to heat exposure and a substantial proportion of ambulance car visits are expected to be occupied by children. This burden would be critical under COVID-19 turmoil, which has already seriously damaged the emergency medical system. Heat impact on children begins before birth;placental abruption, premature rupture of membrane, preterm delivery, stillbirth, low birth weight, and congenital cataract are reported to be related to heat exposure. After birth, emergency visits are related to heat exposure as well. The emergency visits were caused by heat-related illness, general symptoms, infectious diseases, injury, and respiratory diseases. The relation for heatstroke emergency visits was hockey stick type, and higher school-age children had a much higher risk, compared with lower age group children. Mortality risk, mainly external causes, was also associated with heat, but because of the small number of daily deaths, the results were not consistent. A larger multicity study is necessary for robust evidence.

MALIGNANT GLOMUS TUMOR WITH UNSTABLE HEMORRHAGE

SESSION TITLE: Critical Complications of Cancer Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Glomus tumors are rare, benign neoplasms made up of cells resembling modified smooth muscle cells of glomus bodies. Glomus bodies are a type of arteriovenous anastomosis located primarily in dermal soft tissue and responsible for thermoregulation (1). Glomus tumors are suspected when presenting with a classic triad of severe pain, pinpoint tenderness, and hypersensitivity to cold (2). A vast majority of glomus tumors are benign with less than 1% demonstrating malignant pathology. Extradigital glomus tumors can occur, but often lack the typical presentation, making them difficult to diagnose. Treatment is surgical excision. CASE PRESENTATION: We report a case of a 35 year old female with past medical history of diabetes mellitus and morbid obesity who presented with a large 4cmX5cm fungating mass of the left posterior thigh (Figure 1 and 2). The patient was admitted to the ICU for concurrent acute hypoxemic respiratory failure secondary to COVID-19 pneumonia. The patient never received full dose anticoagulation. Due to the patient's instability, surgical evaluation was initially deferred until the patient began experiencing significant hemorrhage from the fungating mass (Figure 3), which correlated with a precipitous drop in hemoglobin requiring multiple transfusions. The mass was surgically excised (Figure 4), but continued bleeding, necessitating blood transfusions. Further evaluation of the mass by pathology established the mass as "Malignant glomus tumor showing chiefly spindle cell morphology, arising from a pre existing benign glomus tumor… showing some stromal oncocytic change as well as degenerative-appearing nuclear atypia and calcification.” The patient remained under ICU care through the remainder of her hospital stay for COVID-19 and sequela. Despite treatment, her clinical status worsened, the patient decompensated secondary to COVID-19, and the decision was made by the family to proceed with comfort measures. DISCUSSION: This patient presented with an abnormal fungating mass without symptoms typically consistent with glomus tumor. The mass displayed a malignant transformation, making it particularly unique. The case was further distinguished by hemorrhage and hemorrhagic shock directly related to the mass. Although this patient experienced a complicated course due to the hemorrhage requiring multiple postoperative transfusions, the patient was eventually stabilized and hemostasis was obtained. While it remains unclear if her malignant glomus tumor conferred increased risk of mortality from COVID-19, it is the author's belief that more research should be done to identify if a relationship between all type cancer and COVID-19 mortality exists. CONCLUSIONS: This case represents a unique case of malignant glomus tumor with previously undescribed presenting symptoms. Reference #1: 1. Gombos, Z., & Zhang, P. J. (2008). Glomus tumor. Archives of Pathology & Laboratory Medicine, 132(9), 1448–1452. https://doi.org/10.5858/2008-132-1448-gt Reference #2: 2. Sbai, M. A., Benzarti, S., Gharbi, W., Khoffi, W., & Maalla, R. (2018). Glomus tumor of the leg: A case report. Pan African Medical Journal, 31. https://doi.org/10.11604/pamj.2018.31.186.9706 Reference #3: 3. Aiba, M., Hirayama, A., & Kuramochi, S. (1988). Glomangiosarcoma in a glomus tumor. An immunohistochemical and ultrastructural study. Cancer, 61(7), 1467–1471. https://doi.org/10.1002/1097-0142(19880401)61:7<1467::aid-cncr2820610733>3.0.co;2-3 DISCLOSURES: No relevant relationships by Syed Akbarullah No relevant relationships by Devin Bradshaw No relevant relationships by LLOYD Del Mundo No relevant relationships by Gerard DiChiara No relevant relationships by Dushawn Harley No relevant relationships by Jerome Hruska No relevant relationships by Ian Ogurek No relevant relationships by Xenia Schneider No relevant relationships by Paul Stewart No relevant relationships by Joseph Telliard No elevant relationships by Ilya Yegudkin

A FEBRILE CRISIS: MONOMORPHIC VENTRICULAR TACHYCARDIA IN A STRUCTURALLY INTACT HEART

SESSION TITLE: Cardiovascular Complications in Patients with COVID-19 SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: COVID-19 infection has been shown to exhibit an array of deleterious cardiac effects specifically arrhythmias. While arrhythmias of ventricular origin are less common, direct insult to the myocardium is cited as the most common etiology [1]. Here we present a unique case of hyperthermia induced monomorphic ventricular tachycardia (VT) in the setting of COVID-19 infection. CASE PRESENTATION: A 65-year-old male with medical history of dyslipidemia and hypertension presented with cough, dyspnea and subsequently diagnosed with COVID-19 pneumonia and was noted to be persistently febrile with a peak temperature of 40.1° C, which coincided with the onset of sustained monomorphic VT for approximately 40 minutes. He was treated with amiodarone. He did not have chest pain and troponin levels were normal. Cooling measures were initiated in the ICU. While normothermic, he did not have episodes of VT until the following day when his temperature again peaked at 40.6° C. A lidocaine drip was started to maintain sinus rhythm. However, due to multi-system organ failure, the family decided to proceed with comfort care. DISCUSSION: COVID-19 infection associated with fatal VT has been documented in the literature mainly attributed to ischemia and myocarditis. [1,2]. COVID-19 virus has the potential to trigger a massive inflammatory response causing systemic illness. Classically, the prototypical patient has a scar from previous ischemic heart disease that allows reentry to occur. Our patient had no prior history of structural heart disease, evidence of acute coronary syndrome or myocarditis. Other known causes of VT were ruled out. It became clear that the patient’s induction of VT had a temporal association with hyperthermia. Once the patient’s temperature was above 40° C, VT would ensue and only terminate with resolution of the fever. Temperature has been shown to affect the transmembrane gradient and the flow velocity of ions through myocardial ion gated channels [3]. These physiological changes could lead to increased automaticity or triggered events that induce VT. Therefore, hyperthermia should not be neglected as a potential trigger for VT in an otherwise intact myocardium. CONCLUSIONS: A systemic illness like COVID-19 associated with cytokine storm can drastically influence the thermal regulation of the body. This can cause a shift in the transmembrane gradient and resting membrane potential, which could in turn alter automaticity. Therefore, hyperthermia could be a possible trigger for monomorphic VT in an otherwise intact myocardium. Early recognition and rapid external cooling are crucial to minimize the risk of ventricular dysrhythmias. Reference #1: Manolis, Antonis S et al. "COVID-19 infection and cardiac arrhythmias.” Trends in cardiovascular medicine vol. 30,8 (2020): 451-460. doi:10.1016/j.tcm.2020.08.002 Reference #2: Bhatla, A., Mayer, M., Adusumalli, S., Hyman, M., Oh, E., Tierney, A., Moss, J., Chahal, A., Anesi, G., Denduluri, S., Domenico, C., Arkles, J., Abella, B., Bullinga, J., Callans, D., Dixit, S., Epstein, A., Frankel, D., Garcia, F., Kumareswaram, R., Nazarian, S., Riley, M., Santangeli, P., Schaller, R., Supple, G., Lin, D., Marchlinski, F. and Deo, R., 2020. COVID-19 and cardiac arrhythmias. Heart Rhythm, 17(9), pp.1439-1444. Reference #3: Huckell, V F et al. "Cardiac Manifestations Of Malignant Hyperthermia Susceptibility.". Circulation, vol 58, no. 5, 1978, pp. 916-925. Ovid Technologies (Wolters Kluwer Health), doi:10.1161/01.cir.58.5.916. Accessed 1 June 2021. DISCLOSURES: No relevant relationships by Robert Cacdac No relevant relationships by Nami Moradi

Employing a Novel Tool for Supportive Clinical Supervision Following Helping Babies Breathe Training in Selected Ethiopian Delivery Room Settings for Targeted Quality Improvement Initiatives

Purpose/Objectives: Helping Babies Breathe (HBB) is a simulation-based curriculum developed to standardize neonatal resuscitation and basic newborn care in low-to-middle income countries. Improvements in neonatal morbidity and mortality following HBB training are inconsistent without ongoing skills practice and integration into local health facilities. We aimed to develop a model of supportive clinical supervision following HBB training to assess clinical skills, identify equipment deficiencies and systems-based barriers to curriculum implementation using a novel checklist tool (Figure 1). Design/Methods: US-based HBB Master Trainers were unable to conduct in-country study activities due to the global COVID-19 pandemic. Alternatively, four graduates of Ethiopia's first Masters of Neonatal Nursing Program (NNP) were recruited to lead curriculum implementation and conduct clinical observations. Baseline knowledge of 12 Masters of NNP students was assessed, followed by a 4-day HBB simulation training course and Objective Structured Clinical Evaluation (OSCE). Master Trainers subsequently observed students implementing HBB in tertiary delivery rooms and completed the HBB Clinical Skills Checklist to characterize barriers to curriculum completion. Results: Students entered the program with wide range of previous years nursing experience (range: 3-11 years) in varied health care settings. 9/12 (75%) students had completed HBB training prior to the study period (range: 2-7 years). Mean score ± SD for pre- and postcurriculum evaluation is reported: HBB Knowledge Check 95 ± 4%, Bag-Mask Ventilation Skill Check 90% ± 8% and OSCE B 96 ± 4%. Master Trainers assessed students during a convenience sample of 6 daytime deliveries (Table 1). Equipment deficiencies were identified, including a lack of gloves, suction, cloths and preterm masks. As a result, 4/6 infants were not “dried thoroughly”. Students appropriately identified “not breathing” and initiated bag-mask ventilation within The Golden Minute®. Contrary to HBB protocol, cords were cut immediately for all infants. 4/5 infants triaged to Routine Care were not placed skinto-skin per OB request. Clinical supervisors noted open doors and windows, significant distance between the delivery and resuscitation area and no water source for hand washing or equipment decontamination. Conclusion/Discussion: Despite the range of clinical experience and prior HBB training, students performed consistently well on OSCE B. Delivery room observations revealed equipment deficiencies that hindered thorough drying. Systems-based barriers prevented delayed cord clamping, immediate skin-to-skin, timely placement in the resuscitation area, environmental thermoregulation and infection control. This model of supportive clinical supervision aids in translating HBB skills from the classroom to local health care systems by identifying barriers to curriculum implementation for targeted quality improvement initiatives. The clinical checklist tool enables tracking of program quality indicators in the domains of clinical performance and facility preparedness. Testing this model on a larger scale with alternative formats for data collection tools (i.e. smartphone Apps) is needed to enable adaptation to other countries where HBB is employed.

Thermal dysregulation in patients with multiple sclerosis during SARS-CoV-2 infection. The potential therapeutic role of exercise.

Thermoregulation is a homeostatic mechanism that is disrupted in some neurological diseases. Patients with multiple sclerosis (MS) are susceptible to increases in body temperature, especially with more severe neurological signs. This condition can become intolerable when these patients suffer febrile infections such as coronavirus disease-2019 (COVID-19). We review the mechanisms of hyperthermia in patients with MS, and they may encounter when infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Finally, the thermoregulatory role and relevant adaptation to regular physical exercise are summarized.

Individual Factors Including Age, BMI, and Heritable Factors Underlie Temperature Variation in Sickness and in Health: An Observational, Multi-cohort Study.

BACKGROUND: Aging affects immunity, potentially altering fever response to infection. We assess effects of biological variables on basal temperature, and during COVID-19 infection, proposing an updated temperature threshold for older adults ≥65 years. METHODS: Participants were from 4 cohorts: 1 089 unaffected adult TwinsUK volunteers; 520 adults with emergency admission to a London hospital with RT-PCR confirmed SARS-CoV-2 infection; 757 adults with emergency admission to a Birmingham hospital with RT-PCR confirmed SARS-CoV-2 infection and 3 972 adult community-based COVID Symptom Study participants self-reporting a positive RT-PCR test. Heritability was assessed using saturated and univariate ACE models; mixed-effect and multivariable linear regression examined associations between temperature, age, sex, and body mass index (BMI); multivariable logistic regression examined associations between fever (≥37.8°C) and age; receiver operating characteristic (ROC) analysis was used to identify temperature threshold for adults ≥ 65 years. RESULTS: Among unaffected volunteers, lower BMI (p = .001), and increasing age (p < .001) was associated with lower basal temperature. Basal temperature showed a heritability of 47% (95% confidence interval 18%-57%). In COVID-19+ participants, increasing age was associated with lower temperatures in Birmingham and community-based cohorts (p < .001). For each additional year of age, participants were 1% less likely to demonstrate a fever ≥37.8°C (OR 0.99; p < .001). Combining healthy and COVID-19+ participants, a temperature of 37.4°C in adults ≥65 years had similar sensitivity and specificity to 37.8°C in adults <65 years for discriminating infection. CONCLUSIONS: Aging affects temperature in health and acute infection, with significant heritability, indicating genetic factors contribute to temperature regulation. Our observations suggest a lower threshold (37.4°C/97.3°F) for identifying fever in older adults ≥65 years.

Analysis of Physiological Response during Cardiopulmonary Resuscitation with Personal Protective Equipment: A Randomized Crossover Study.

The use of personal protective equipment (PPE) is required for the self-protection of healthcare workers during cardiopulmonary resuscitation (CPR) in patients at risk of aerosol transmission of infectious agents. The aim of this study was to analyze the impact of personal protective equipment on physiological parameters during CPR. A randomized, quasi-experimental, crossover design was used. The study was carried out in a training and simulation emergency box and the total sample consisted of 20 healthcare professionals. Two CPR tests were compared with the recommended sequence of 30 chest compressions and 2 ventilations. The duration of each test was 20 min. One of the CPR tests was carried out without using any PPE (CPR_control), i.e., performed with the usual clothing of each rescuer. The other test was carried out using a CPR test with PPE (i.e., CPR_PPE). The main variables of interest were: CPR quality, compressions, ventilations, maximum heart rate, body fluid loss, body temperature, perceived exertion index, comfort, thermal sensation and sweating. The quality of the CPR was similar in both tests. The maximum heart rate was higher in the active intervals (compressions + bag-valve-mask) of the test with PPE. CPR_PPE meant an increase in the perceived effort, temperature at the start of the thermal sensation test, thermal comfort and sweating, as opposed to CPR performed with usual clothing. Performing prolonged resuscitation with PPE did not influence CPR quality, but caused significant physiological demands. Rescuers were more fatigued, sweated more and their thermal comfort was worse. These results suggest that physical preparation should be taken into account when using PPE and protocols for physiological recovery after use should also be established.

Tympanic thermometers support fast and accurate temperature monitoring in acute and alternative care.

This article explores body temperature and the physiological process of thermoregulation. Normal body temperature and body temperature changes are discussed, including comorbidities associated with body temperature and signs of hyperthermia and hypothermia, and the factors that affect intraoperative temperature regulation. The evidence base behind thermometry is discussed and is applied to contemporary clinical conditions and symptoms, including: sepsis and suspected COVID-19. After discussing clinical considerations and regulations that encompass thermometry, three case studies present the use of the Genius 3 Tympanic Thermometer in clinical practice, with user feedback supporting its benefits, which include speed, accuracy and ease of use.

Cooling vests alleviate perceptual heat strain perceived by COVID-19 nurses.

Cooling vests alleviate heat strain. We quantified the perceptual and physiological heat strain and assessed the effects of wearing a 21°C phase change material cooling vest on these measures during work shifts of COVID-19 nurses wearing personal protective equipment (PPE). Seventeen nurses were monitored on two working days, consisting of a control (PPE only) and a cooling vest day (PPE + cooling vest). Sub-PPE air temperature, gastrointestinal temperature (Tgi), and heart rate (HR) were measured continuously. Thermal comfort (2 [1-4] versus 1 [1-2], pcondtition < 0.001) and thermal sensation (5 [4-7] versus 4 [2-7], pcondition < 0.001) improved in the cooling vest versus control condition. Only 18% of nurses reported thermal discomfort and 36% a (slightly) warm thermal sensation in the cooling vest condition versus 81% and 94% in the control condition (OR (95%CI) 0.05 (0.01-0.29) and 0.04 (<0.01-0.35), respectively). Accordingly, perceptual strain index was lower in the cooling vest versus control condition (5.7 ± 1.5 versus 4.3 ± 1.7, pcondition < 0.001, respectively). No differences were observed for the physiological heat strain index Tgi and rating of perceived exertion across conditions. Average HR was slightly lower in the cooling vest versus the control condition (85 ± 12 versus 87 ± 11, pcondition = 0.025). Although the physiological heat strain among nurses using PPE was limited, substantial perceptual heat strain was experienced. A 21°C phase change material cooling vest can successfully alleviate the perceptual heat strain encountered by nurses wearing PPE.