ID: 215433 The History of Spinal Cord Stimulation to Treat Painful Diabetic Peripheral Neuropathy

Introduction: Diabetic peripheral neuropathy (DPN) is the most common neuropathic syndrome seen in patients with diabetes. Roughly 30% of the diabetes patient population1 experience painful DPN symptoms including bilateral stabbing or burning pain in addition to numbness in the feet and lower legs. Traditionally painful DPN symptoms have been treated with conventional medical management (CMM) including glycemic control, general risk factor management, as well as pharmaceutical agents. These treatment approaches are often unsuccessful in the long-term1. Spinal cord stimulation (SCS) has been demonstrated as an effective treatment for painful DPN of the lower extremities with multiple publications dating back to 1996 showing benefits of SCS for pain relief and improved Quality of Life (QoL) in DPN patients (Figure 1)2-18. Method(s): A systematic literature review of the robust body of evidence for SCS in the treatment of painful DPN was conducted. Publications were selected for inclusion by two independent reviewers using defined selection criteria. Additional relevant publications from outside the search dates were included. Result(s): SCS was first documented as an effective treatment for DPN in three single-arm studies published between 1996 and 20122,4,5, one of which was followed-up to thirty-six months18, and another to seven-years3. These studies paved the way for two RCTs published in 20146,7, one of which was followed-up to five-years in two publications8,10, and another7 was followed-up with analyses on QoL9 and an evaluation of the effects of burst SCS17. Two meta-analyses were published in 2020 and 202111,12. A post-hoc analysis of a multi-center single-arm study on high frequency (10kHz) SCS to treat DPN was published in 202013 and followed by an RCT published in 202114 with additional 1-year follow-up15,16. Collectively these studies demonstrate that SCS is an effective therapy for patients with painful DPN by reducing pain and increasing QoL for DPN patients (Figure 1). Conclusion(s): This review of a large body of evidence shows a decades-long history of the effectiveness of SCS for symptom relief in patients suffering from painful DPN. Future research on the effectiveness of new waveforms and novel methods of energy delivery to the spinal cord are needed. The study of outcomes in addition to pain relief is also needed, which may better illustrate the breadth of effects of SCS therapy on the underlying disease factors. Increasing awareness of the current evidence is essential to increasing therapy adoption by expanding payer support and influencing referring health care provider behavior. Disclosure: Eric Grigsby, MD: AE Mann Foundation: Consulting Fee: Self, Bioness Inc.: Consulting Fee: Self, Medallion Therapeutics: Consulting Fee: Self, Medtronic: Consulting Fee: Self, SPR Therapeutics: Consultant: Self, Tenex Health: Consultant: Self, Voyager Therapeutics: Consultant: Self, Xalud: Consulting Fee: Self, AE Mann Foundation: Consulting Fee: Self, Medallion Therapeutics: Consulting Fee: Self, Bioness Inc.: N/A: Self, Medallion Therapeutics: N/A: Self, SPR Therapeutics: N/A: Self, Abbott / St. Jude Medical: N/A: Self, Tenex: N/A: Self, Vertos: N/A: Self, Xalud: N/A: Self, AE Mann Foundation: Consulting Fee: Self, Bioness Inc.: Consulting Fee: Self, Medtronic, Inc.: N/A: Self, Collegium Pharmaceutical, Inc.: Trustee: Self, Flowonix Medical: Served on speakers' bureau: Self, Jazz Pharmaceuticals: Served on speakers' bureau: Self, Jazz Pharmaceuticals: Trustee: Self, Spinal Restoration, Inc.: Trustee: Self, Jazz Pharmaceuticals: N/A: Self, Alfred Mann Foundation: N/A: Self, Boston Scientific: N/A: Self, CNS Therapeutics: N/A: Self, Collegium Pharmaceutical, Inc.: N/A: Self, Flowonix Medical: N/A: Self, Jazz Pharmaceuticals: N/A: Self, Medtronic, Inc.: N/A: Self, Myoscience: N/A: Self, NeurAxon Inc.: N/A: Self, Spinal Restoration, Inc.: N/A: Self, St. Jude Medical, Inc.: N/A: Self, Abbott Laboratories: Consultant: Self, Alfred Mann Foundation: Consulting Fee: Self, Cervel Neurotech, Inc.: Consultant: Self, CNS Therapeutics: Consultant: Self, Covidien: Consultant: Self, Cumberland Pharmaceuticals, Inc.: Consultant: Self, Flowonix Medical: Consultant: Self, Jazz Pharmaceuticals: Consultant: Self, Mainstay Medical: Consultant: Self, Medtronic, Inc.: Consultant: Self, Myoscience: Consultant: Self, NeuroPhage Pharmaceuticals: Consultant: Self, Nevro Corp: Consultant: Self, Palyon: Consultant: Self, Spinal Modulation: Consultant: Self, SPR Therapeutics: Consultant: Self, St. Jude Medical, Inc.: Consultant: Self, Tenex Health, Inc.: Consultant: Self, VertiFlex Inc.: Consultant: Self, Vertos Medical, Inc.: Consultant: Self, Xalud Therapeutics, Inc.: Contracted Research: Self, Medtronic, Inc.: Served on speakers' bureau: Self, Flowonix Medical: Served on advisory board: Self, Medtronic, Inc.: N/A: Self, Jazz Pharmaceuticals: N/A: Self, Medtronic, Inc.: Ownership Interest: Own Stock, Stock Options, Future Stock Options: Self, Nevro Corp: Ownership Interest: Own Stock, Stock Options, Future Stock Options: Self, Rachel Slangen, PhD: None, Lisa Johanek, PhD: Medtronic: Salary/Employee: Self, Maddie LaRue, PHD: Medtronic: Employee:, Cecile de Vos, PhD: None, Melissa Murphy: Medtronic: Consulting Fee:, Relievant: Consulting Fee:Copyright © 2023

Demonstration of Remote Control of Critical Care Ventilators and the Integrated Clinical Environment

Introduction: The COVID-19 pandemic posed numerous challenges to patient care, including extensive PPE use, patient care in isolation rooms, inadequate numbers of intensivists particularly in rural communities, use of unfamiliar ventilators that would be partially remedied by the ability to remotely control lung ventilation. The goals of the project were to study the intended use, risk management, usability, cybersecurity for remote control of ventilators and demonstrate the use of a single interface for several different ventilators. Method(s): Clinical scenarios were developed including remote control of the ventilator from an antechamber of an isolation room, nursing station within the same ICU, and remote control from across the country. A risk analysis and was performed and a risk management plan established using the AAMI Consensus Report--Emergency Use Guidance for Remote Control of Medical Devices. A cybersecurity plan is in progress. Testing was done at the MDPNP laboratory. We worked with Nihon Kohden OrangeMed NKV-550, Santa Ana, CA, and Thornhill Medical MOVES SLC, Toronto, Canada. Both companies modified their devices to allow remote control by and application operating on DocBox's Apiary platform. Apiary is a commercially available ICE solution, DocBox Inc, Waltham, MA. An expert panel was created to provide guidance on the design of a single common, simple to use graphical user interface (GUI) for both ventilators. Manufacturers' ventilation modes were mapped to ISO 19223 vocabulary, data was logged using ISO/IEEE 11073-10101 terminology using AAMI 2700-2-1, Medical Devices and Medical Systems - Essential safety and performance requirements for equipment comprising the patient-centric integrated clinical environment (ICE): Part 2-1: Requirements for forensic data logging. Result(s): We demonstrated that both ventilators can be controlled and monitored using common user interface within an institution and across the country. Pressure and flow waveforms were available for the NKV-550 ventilator, and usual ventilator measurements were displayed in near-real time. The interface allowed changing FiO2, ventilation mode, respiratory rate, tidal volume, inspiratory pressure, and alarm settings. At times, increased network latency negatively affected the transmission of waveforms. Conclusion(s): We were able to demonstrate remote control of 2 ventilators with a common user interface. Further work needs to be done on cybersecurity, effects of network perturbations, safety of ventilator remote control, usability implications of having a common UI for different devices needs to be investigated.

Pseudo-V1 ECG lead recording with quality smartwatches and medical interpretation may be necessary for timely and accurate remote detection of atrial flutter/fibrillation

Background: Remote rhythm monitoring with wearable devices is increasingly used especially for early detection of atrial fibrillation/flutter (AF/Afl), being the access to hospital discouraged, especially for frail elderly patients, due to the burden and risk of COVID-19 pandemic. Whereas devices using photo plethysmography (PPG) may misinterpret as AF pulse irregularities due to extrasystoles, patient-directed recording of a single (usually wrist-to-wrist) lead ECG (LEAD I) with hand-held devices or smartwatches have been developed to increase accuracy in AF detection. However, although recent studies validating such devices single-lead ECG recording have shown high sensitivity and specificity, false negative findings such as those reported here are still possible and must be prevented [1]. Purpose(s): Given previous experience of diagnostic uncertainty or failure of the smartwatch ECG (SW-ECG) LEAD I to detect AF/Afl, we have tested if false negative diagnosis could be avoided by recording in addition at least one right precordial (pseudo-V1) lead analyzed by a trained healthcare professional. Method(s): Over one calendar year observation, five patients with previous history of ablated supraventricular arrhythmias suffering sudden palpitations suspected of paroxysmal AF/Afl were instructed to record with their smartwatch at least one precordial lead in addition to LEAD I, to monitor ECG until the termination of symptoms. The SW-ECG strips were sent by telephone for professional interpretation. Diagnostic accuracy based on LEAD I and pseudo-V1 were independently validated by two cardiologists (diagnostic goldstandard - DGS). Result(s): 22 AF/Afl events occurred. Pharmacological cardioversion to sinus rhythm (SR) was obtained in 64%. 192 ECG strips were transmitted. 43,7% of the strips were automatically classified as not significant (or not valid ). Compared to DGS, out of 108 valid strips, correct automatic identification of AF/Afl was obtained in 36,4% with LEAD I, in 33,3% with pseudo V1 and in 54,5% with combined leads, respectively. Interestingly, the SW algorithm has wrongly diagnosed as SR, not only LEAD I, but also 39,4% of pseudo-V1 strips, despite clear-cut evidence of typical flutter waves (Figure 1), when RR intervals were regular due to high degree (e.g., 4:1) A-V block. Conclusion(s): With simple instructions, patients (or their relatives) can easily record an additional precordial (pseudo-V1) SW-ECG lead, that may enhance sensitivity and specificity for remote detection of AF/Afl. However, at present, visual interpretation of SW-ECG by a trained healthcare professional is still needed to guarantee 100% correct diagnosis of AF/Afl, crucial to reduce thromboembolic risk and timely initiate the appropriate treatments. The automatic interpretation of SW's ECG could be improved by appropriate training of a machine learning approach to detect and analyze the atrial waveform provided by an additional pseudo-V1 lead.

Amplitude Spectrum Area of ventricular fibrillation to guide defibrillation: a small open-label, pseudo-randomized controlled multicenter trial.

BACKGROUND: Ventricular fibrillation (VF) waveform analysis has been proposed as a potential non-invasive guide to optimize timing of defibrillation. METHODS: The AMplitude Spectrum Area (AMSA) trial is an open-label, multicenter randomized controlled study reporting the first in-human use of AMSA analysis in out-of-hospital cardiac arrest (OHCA). The primary efficacy endpoint was the termination of VF for an AMSA ≥ 15.5 mV-Hz. Adult shockable OHCAs randomly received either an AMSA-guided cardiopulmonary resuscitation (CPR) or a standard-CPR. Randomization and allocation to trial group were carried out centrally. In the AMSA-guided CPR, an initial AMSA ≥ 15.5 mV-Hz prompted for immediate defibrillation, while lower values favored chest compression (CC). After completion of the first 2-min CPR cycle, an AMSA < 6.5 mV-Hz deferred defibrillation in favor of an additional 2-min CPR cycle. AMSA was measured and displayed in real-time during CC pauses for ventilation with a modified defibrillator. FINDINGS: The trial was early discontinued for low recruitment due to the COVID-19 pandemics. A total of 31 patients were recruited in 3 Italian cities, 19 in AMSA-CPR and 12 in standard-CPR, and included in the data analysis. No difference in primary outcome was observed between the two groups. Termination of VF occurred in 74% of patients in the AMSA-CPR compared to 75% in the standard CPR (OR 0.93 [95% CI 0.18-4.90]). No adverse events were reported. INTERPRETATION: AMSA was used prospectively in human patients during ongoing CPR. In this small trial, an AMSA-guided defibrillation provided no evidence of an improvement in termination of VF. TRIAL REGISTRATION: NCT03237910. FUNDING: European Commission - Horizon 2020; ZOLL Medical Corp., Chelmsford, USA (unrestricted grant); Italian Ministry of Health - Current research IRCCS.

Camera-Based Blood Pressure Estimation via Windkessel Model and Waveform Features

Blood pressure (BP) is generally regarded as the vital sign most strongly correlated with human health. However, for decades, BP measurement has involved a cuff, which causes discomfort and even carries a risk of infection, given the current prevalence of COVID-19. Some studies address these problems using remote photoplethysmography (rPPG), which has shown great success in heart rate detection. Nevertheless, these approaches are not robust, and few have been evaluated with a sufficiently large dataset. We propose an rPPG-based BP estimation algorithm that predicts BP by leveraging the Windkessel model and hand-crafted waveform characteristics. A waveform processing procedure is presented for the rPPG signals to obtain a robust waveform template and thus extract BP-related features. Redundant and unstable features are eliminated via Monte Carlo simulation and according to their relationship with latent parameters (LSs) in the Windkessel model. For a comprehensive evaluation, the Chiao Tung BP (CTBP) dataset was constructed. The experiment was conducted over a four-week period of time to evaluate the validity period of the personalization in our system. On all the data, the proposed method outperforms the benchmark algorithms and yields mean absolute errors (MAEs) of 6.48 and 5.06 mmHg for systolic BP (SBP) and diastolic BP (DBP), respectively. The performance achieves a 'B' grade according to the validation protocol from the British Hypertension Society (BHS) for both SBP and DBP. © 1963-2012 IEEE.

Transcutaneous Electrical Cranial-Auricular Stimulation (Tecas) for Treatment of Insomnia Disorder with Comorbid Major Depressive Disorder: A Case Series: E-Poster Viewing

Introduction: Insomnia disorder (ID) and major depressive disorder (MDD) are highly comorbid, above 80% of MDD patients have insomnia disorder. Acupuncture as a major complementary and alternative medicine (CAM) therapy, is utilized extensively in Asia to treat mental health disorders.Transcutaneous electrical cranial-auricular stimulation (TECAS) is a potential new type of acupuncture treatment for MDD and ID which combines the scalp points and auricular points most commonly used by acupuncturists. It has the advantages of portability, quantifiable stimulation parameters and comfort, especially for home treatment under the normal situation of COVID-19, which can avoid the risk of infection due to frequent hospital trips. Materials / Methods: 10 ID-MDD patients were treated by TECAS which was administered at the bilateral auricular acupoints, Bai Hui (GV-20) and Yin Tang (GV-29) (waveform:4/20 Hz, wave width: 0.2ms+/-30%) for twice a day last 8 weeks. Pittsburgh Sleep Quality Index (PSQI) and Hamilton Depression Rating Scale(HAMD) of ID-MDD patients were evaluated before and after treatment. Result(s): HAMD-17 scores of 10 patients were lower at 4 and 8 weeks than before TECAS treatment, and the reduction was greater at 4 weeks than at 8 weeks. PSQI scores of 8 patients decreased at 4 and 8 weeks compared with before treatment, and the decrease was greater in the fourth week than in the 8th week. Insomnia of 2 patients improved at 4 weeks of treatment, but became worse in the 8th week as before treatment.7 out of 10 patients showed full insomnia response (50% reduction in PSQI) and 8 patients showed full depression response (50% reduction in HAMD-17 scores). Discussion(s): We suggest TECAS is a good therapeutic strategy to modulate the vagus nerve and trigeminal nerve propagate through electrical stimulation projected by neurons from peripheral sites to the central nervous system. Furthermore, we speculate that TECAS can make the trigeminal nerve afferent fibers and vagus nerve auricular branch carry messages from head facial stimulation to NTS, locus coeruleus, raphe nucleus, medullary reticular activating system and structure of the thalamus, and then to feel, edge, cortical and subcortical structures, so the electrical stimulation subcortical can cause direct regulation, namely the change of cortical excitability. Conclusion(s): These preliminary results in this group of CID-MDD patients are encouraging and need to be replicated in prospective sham-controlled studies with larger sample sizes. In addition, for patients with insomnia and depression, it is important to consider combining TECAS with psychotherapy to avoid the interference of acute negative emergency events. Acknowledgements: The support of National Key R&D Program of China (No.2018YFC1705800) and Key Laboratory of Acupuncture and Chronobiology of Sichuan Province(No.2021004) for this project is gratefully acknowledged. Learning Objectives: 1. To provide a new non-drug method for acupuncture treatment of insomnia and depression;2. Provide preliminary experimental results for the large-sample experimental design of TECAS for the treatment of insomnia and depression;3. Compared with previous studies on insomnia and depression, the regularity and characteristics of TECAS in treating insomnia and depression were found. Keywords: Transcutaneous Electrical Cranial-Auricular Stimulation (TECAS), insomnia disorder, a case series, acupuncture, Major Depressive Disorder Copyright © 2022

CARDIAC TAMPONADE AS A DEADLY COMPLICATION OF TENSION PNEUMOPERICARDIUM: A CASE REPORT

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: Pneumopericardium is the presence of air or gas in the pericardial space, usually secondary to blunt or penetrating trauma. Most pneumopericardium are non-tension. The use of positive pressure ventilation (PPV) increases the chances of developing a tension pneumopericardium. We report the case of a 22-year-old male patient admitted for COVID-19 pneumonia who developed pneumopericardium with cardiac tamponade features. CASE PRESENTATION: A 22-year-old male was admitted for acute respiratory distress syndrome due to COVID-19 pneumonia and required intubation on hospital day 10. The next day, he became febrile with new leukocytosis. A chest x-ray showed new extensive pneumomediastinum and pneumopericardium. Vasopressor support and broad-spectrum antibiotics were started for septic shock, however he continued to decompensate rapidly, requiring maximal medical support. His arterial line waveform showed pulsus paradoxus, leading to concern for underlying tension pneumopericardium. Bedside echo was unrevealing as imaging was obstructed by the air in pericardial sac. The patient was too unstable for a CT scan of the chest. After extensive discussion with his family, he was placed on palliative measures only and expired. DISCUSSION: Pneumopericardium is due to an abnormal connection between the pericardial space and a source of air or gas. Levin and Macklin describe three main mechanisms by which this connection can be made. The first: acute rises in alveolar pressure and volume or ventilator associated lung injury leading to rupture of alveoli with gas tracking along perivascular and peri bronchial sheaths to the mediastinum. The second: macro-perforation of the pericardial space leading to communication with respiratory or gastrointestinal tracts. Third: existence of a pneumothorax in the presence of traumatic pericardial tear or congenital pleuro-pericardial connection. Spontaneous pneumopericardium without any anatomic connection is rare and is due to a direct extension of infectious etiologies of the lungs or by an infection of the pericardial space with gas forming bacteria. A tension pneumopericardium causing cardiac tamponade can develop from pneumopericardium with PPV where the pericardial sac acts as a shutter valve letting air in but not out as has been reported sparingly in the literature. Cummings et al described 93 patients who developed tamponade out of 252 patients with pneumopericardium. Our patient possibly developed a pleuro-pericardial tract secondary to his pneumonia. With continued PPV his simple pneumopericardium likely developed into a tension pneumopericardium evidenced by arterial waveforms consistent with pulsus paradoxus, worsening hypotension despite maximal vasopressor support and development of ventricular tachycardia. CONCLUSIONS: Our case highlights the importance of considering pneumopericardium causing cardiac tamponade in the setting of mechanical ventilation. Reference #1: Mindaye ET, Arayia A, Tufa TH, Bekele M. Iatrogenic pneumopericardium after tube thoracostomy: A case report. Vol. 76, International journal of surgery case reports. 2020. p. 259–62. Reference #2: Cummings RG, Wesly RL, Adams DH, Lowe JE. Pneumopericardium resulting in cardiac tamponade. Ann Thorac Surg. 1984 Jun;37(6):511–8. Reference #3: Levin AI, Visser F, Mattheyse F, Coetzee A. Tension pneumopericardium during positive-pressure ventilation leading to cardiac arrest. J Cardiothorac Vasc Anesth. 2008 Dec;22(6):879–82. MACKLIN CC. TRANSPORT OF AIR ALONG SHEATHS OF PULMONIC BLOOD VESSELS FROM ALVEOLI TO MEDIASTINUM: CLINICAL IMPLICATIONS. Arch Intern Med [Internet]. 1939 Nov 1;64(5):913–26. Available from: https://doi.org/10.1001/archinte.1939.00190050019003 DISCLOSURES: No relevant relationships by Aarti Mittal No relevant relationships by Beenish Naqvi

Intra-oral kinking of a micro-cuff endotracheal tube: an unusual cause of difficult ventilation

Background: Intra-oral kinking of endotracheal tube is a rare but not unheard of complication. It could be lifethreatening if left unrecognised. Case presentation: A ten-year-old boy with developmental delay, scoliosis and recurrent chest infections was transferred to our paediatric intensive care (PIC) with SARS-CoV-2 pneumonia. The child was intubated with a size 5.5 micro-cuff endotracheal tube for critical hypoxic respiratory failure at his local hospital. The intubation was reported to be straightforward, with a grade 1 laryngoscopy view, but he was notably difficult to ventilate and oxygenate on the ventilator. He was transferred by road and was requiring a fraction of inspired oxygen of 0.8 and inhaled nitric oxide at 20 parts per million to maintain oxygen saturations of greater than 94%. The retrieval team also reported that he required a peak inspiratory pressure of as high as 49 cmH2O and positive end-expiratory pressure of 8 cmH2O with a 1:1 I: E ratio to maintain tidal volume of 6 ml/kg for his weight of 30kg. He was fully sedated and paralysed. The child was examined on arrival to PIC. His trachea was central and there was no wheeze or abdominal distension. The capnography waveforms were of normal appearance. A chest X-ray was also done to exclude endobronchial intubation and obvious pneumothorax. He was noted to be unusually difficult to bag ventilate, and the delivery of tidal volumes were hugely variable with any change in head positioning. He was best ventilated with head-tilt and chin-lift. Our concerns were escalated when the 'red-flag' of inability to pass the suction catheter was highlighted by the nursing team. The course of his tracheal tube was immediately palpated, and a twist was felt in the oropharynx. This finding was confirmed on laryngoscopy, which revealed a significant kink at letter C of this micro-cuff tube (Figure 1). The airway was swiftly exchanged, and immediate improvements of both ventilation and gas exchanged were observed. Conclusion: The polyvinyl polymers of endotracheal tubes are known to soften at body temperature and have a higher tendency to bent at acute angles,1 where the pilot tubing exists2;and when bending forces are applied away from the anatomical curvature, also known as the Magill curve (radius of approximately 140 millimetres), of most conventional tracheal tubes.2-5 Kinking of endotracheal tube at blind spots such as within the pharynx may happen more frequently in paediatrics than in adult critical care practice due to the use of straighter tracheal tubes with smaller wall thickness. We would like to raise awareness of this unusual case of difficult bag ventilation and high airway pressure ventilation. If a well-secured tracheal tube suddenly becomes problematic following, or in relation to positional changes, tube malfunction should be suspected. The integrity of the endotracheal tube must also be interrogated.

Apnoeic oxygenation with a rigid bronchoscope during cardiopulmonary resuscitation

Introduction: The potential utility of apnoeic oxygenation combined with continuous chest compressions during cardiopulmonary resuscitation (CPR) is recognised in ERC Guidelines but is not routinely recommended. Case Presentation: A female 73 years old patient, ASA PS 3, with a recent hospitalization because of COVID 19, was scheduled for lung cancer staging mediastinoscopy. After anesthesia induction, patient exhibited difficult ventilation due to increased airway pressures. Direct bronchoscopy with a fiberoptic bronchoscope was conducted, which revealed trachea compression due to an extra tracheal tumor at the level of the carina. Initially, tumor debulking was attempted with the fiberoptic bronchoscope and, thereafter, with the rigid one. During those attempts, patient suffered a pulseless electrical activity (PEA) cardiac arrest (CA). Immediate CPR with chest compressions was performed. Tracheal occlusion was negotiated with the help of the rigid bronchoscope and apnoeic oxygenation was applied since ventilation with the anesthesia ventilator was not effective (Fig. 1). Chest compressions qualitywas evaluatedby usingdata fromthearterial pressure waveform (Fig. 2). Return of spontaneous circulation (ROSC) was achieved after 10 min CPR and administration of 2 mg of epinephrine. AfterROSC, oral endotracheal intubationwas accomplished and patient was transferred to the ICU (Fig. 3). She remained under sedation for 24hrs and was extubated after 30hrs in good condition. PaCO2 after ROSC was 120mmHg compared to 55 mHg before CA, whereas PaO2 was 230 mmHg compared to 250 mmHg before CA. (Figure Presented) Conclusions: Apnoeic oxygenation is awell-established technique since many years1. It can be combined with several other techniques, can be applied in various clinical settings and is an oxygenation alternative during CPR2

Supplement-Induced Thyrotoxicosis Presenting as New Onset Tachycardia

INTRODUCTION: Dietary and herbal supplements can contain clinically significant amounts of exogenous thyroid stimulants and hormones, including T3 and T4, thus placing consumers at increased risk of thyrotoxicosis and other metabolic-related adverse effects. We present a case of thyrotoxicosis in a young man with no history of thyroid disease, who was found to be consuming an extensive variety of supplements. DESCRIPTION: A 31 year old man with hypertension presented with 1 week of intermittent palpitations. He was in his usual state of health until 1 week prior to admission, when he noticed intermittent, self-resolving episodes of tachycardia as high as the 160s on his smart watch, associated with palpitations, dyspnea, low grade fevers, and intermittent dry cough. He came to the ED for persistence of symptoms. In the ED: T 98.8 F, HR 129, BP 152/77, RR 18, SpO2 98% on RA. CBC, BMP, UA, UTox, blood alcohol content, troponin and COVID tests were unremarkable. TSH was < .007 [0.358-3.740 ulU/mL], with a free thyroxine of 0.54 [0.70-1.48 ng/dL];other thyroid studies later returned with TSI < 0.10 [0.00-0.55 IU/L], free T3 32.50 [1.80-4.60 pg/mL], and an unremarkable thyroid ultrasound. CXR showed no acute infiltrates. EKG revealed sinus tachycardia, no Wolff-Parkinson-White syndrome, and no Brugada waveforms. He was given 2L NS, ceftriaxone 1g IV, aspirin 81mg PO, and tylenol 650mg PO, and admitted to the telemetry unit. Exam revealed an anxious appearing man with tachycardia. On ROS, patient admitted to drinking 6-8 cups of coffee daily, and to taking at least a dozen different supplements. He was started on propranolol 30 mg every 6 hours with improvement in his heart rate, and was counseled to stop the supplements and wean his caffeine intake. He was discharged the following day with plan for endocrinology and primary care follow-up. DISCUSSION: Thyrotoxicosis in this young patient with no history of thyroid disease posed a diagnostic quandary. This prompted further investigation into a more detailed social history, which revealed the extensive variety of supplements he was taking, consistent with thyrotoxicosis factitia. In patients presenting with newonset tachycardia, our case highlights the importance of collecting a thorough social history and maintaining early suspicion for thyroid disease and thyrotoxicosis.

Demographic Comparison of the First and the Second Waves of Covid-19 Disease: A Study in a Tertiary Care Hospital of North India

Introduction: The new corona virus, also known as COVID-19, is a virus that causes respiratory disease. It was discovered in December 2019 in Wuhan, China, and has spread to other countries. Corona viruses are large, enveloped, positive-stranded RNA viruses. On March 11, 2020, the World Health Organization (WHO) designated the viral outbreak a worldwide pandemic. As of September 15, 2021, the virus has infected over 226672138 individuals and killed over 4663045 infected ones. India accounts for 14.7% of infections (more than 33 million) and 9.5% of fatalities (more than 4 million). Aim and Objectives: This hospital-based, retrospective study was conducted in the Department of Microbiology, SKIMS Soura, Srinagar. We designed this study with the following primary objectives: 1. To estimate and analyze SARS-CoV-2 infection positive rate during first and second covid-19 waveforms. 2. Estimate the pattern of 1st and 2nd Covid-19 waveform. Material and Methods: All pertinent clinical, demographic, and epidemiological data were collected during peak months of COVID-Wave I (Sep-Dec 2020) & COVID-Wave II (April-July 2021).The samples obtained from patients visiting Covid-19 clinic (OPD) and IPD were processed in the bio safety level II lab. A real-time RT-PCR test was utilized in line with the manufacturer's instructions to detect ribonucleic acid (RNA) of SARS-CoV-2 from VTM’s containing NP/OP swabs from patients suspected of COVID-19. A positive result on a realtime RT-PCR assay of nasopharyngeal and/or oropharyngeal swab specimens were defined as a confirmed case of Covid-19. Results: A total of 27851 patients were included in our study in peak months of the1st wave (September to December 2020) of COVID-19 and 31871 patients in the 2nd wave (April to July 2021). The findings of this study demonstrate that during the first and the second-wave, hospitalized patients were majority males, younger in the age group of 19-30 years. The majority of patients during the first wave of COVID-19 reported in the out-patient department, while during the second wave, patients reported through the In-patient department of the hospital. Also, the total number of cases reported and positivity rate during the COVID-19 first wave was less than the second wave. Conclusion: We compared the baseline characteristics of wave II with that of Wave I, in which we found that in COVID wave II more individuals were affected, the younger population was infected, more patients were admitted. We also found that the pattern of the two waves does not show any seasonality. Our data could be used to inform Kashmiri population about the epidemiology and demography of Covid-19 waves so that people understand the nature of the situation and follow all the COVID-19 appropriate behaviours more strictly.

Clinical application of clot waveform analysis

Bleeding and thrombotic diseases are closely related to various clinical departments. Laboratory‐related tests play an important role in disease diagnosis and differential diagnosis, risk assessment, cause finding, and efficacy monitoring. Clot waveform analysis (CWA), as an automated coagulation detection technology, can provide more valuable information about the entire coagulation process of a plasma sample. A large number of studies have showed that CWA has certain value in the evaluation of coagulation status of COVID‐19 patients, the judgment of clinical phenotype of hemophilia A (HA) patients, and the monitoring of direct oral anticoagulant drugs (DOAC). In‐depth interpretation and application of CWA in different clinical settings can provide more laboratory information for diagnosis and treatment of bleeding and thrombotic diseases. © 2021 Chinese Medical Journals Publishing House Co.Ltd. All rights reserved.

高分七号卫星激光测高仪无场几何定标法

无场几何定标是未来多波束激光测高卫星面临的一个关键问题。本文针对高分七号(GF-7)线性体制全波形激光测高仪, 提出了一种基于地形和波形匹配的无场分步定标方法。在深入分析高分七号卫星激光测高仪特点的基础上, 构建了严密几何定位模型, 采用公开版的地形参考数据和某地区1∶2000高精度的DOM和LiDAR-DSM基础地理信息成果, 开展了在轨无场几何定标试验, 显著提高了高分七号卫星激光测高数据精度。在2020年上半年受新冠肺炎影响未进行外场定标期间, 有效解决了激光测高数据处理无定标参数的实际困难。本文对无场定标结果与高分七号实际外场定标结果进行对比验证, 结果表明, 无场定标结果与实际落点位置的平面误差为11.597±3.693 m, 最小值为7.115 m, 平坦地区高程精度优于0.3 m, 虽然略低于外场定标结果, 但能满足1∶10 000高程控制点测量需求。Alternate : On-orbit geometric calibration without field site is a key problem for future multi-beam laser altimetry satellites. In view of the linear system full waveform laser altimeter loaded on the GF-7 satellite, a non-field step by step calibration method based on terrain and waveform matching is proposed. Based on the analysis of the characteristics of the GF-7 satellite laser altimeter, a rigorous geometric positioning model is constructed. The field-free on orbit geometric calibration test is carried out by using the open topographic reference data and the basic geographic information of DOM and LiDAR DSM in a certain area, which has greatly improved the accuracy of the laser altimetry data. With this method, during the first half of 2020, the calibration parameter configuration and data processing of GF-7 satellite laser altimeter was not affected, even the field calibration can't be implemented due to the negative impact of the COVID-19. The accuracy is compared with the field calibration results after the COVID-19, and the results show that the plane error of the non-field calibration is 11.597±3.693 m and the minimum value is 7.115 m. The elevation accuracy of flat area is better than 0.3 m, although it is slightly lower than the results of field calibration, it can basically meet the requirements of 1:10 000 elevation control points.

The method of GF-7 satellite laser altimeter on-orbit geometric calibration without field site

On-orbit geometric calibration without field site is a key problem for future multi-beam laser altimetry satellites. In view of the linear system full waveform laser altimeter loaded on the GF-7 satellite, a non-field step by step calibration method based on terrain and waveform matching is proposed. Based on the analysis of the characteristics of the GF-7 satellite laser altimeter, a rigorous geometric positioning model is constructed. The field-free on orbit geometric calibration test is carried out by using the open topographic reference data and the basic geographic information of DOM and LiDAR DSM in a certain area, which has greatly improved the accuracy of the laser altimetry data. With this method, during the first half of 2020, the calibration parameter configuration and data processing of GF-7 satellite laser altimeter was not affected, even the field calibration can't be implemented due to the negative impact of the COVID-19. The accuracy is compared with the field calibration results after the COVID-19, and the results show that the plane error of the non-field calibration is 11.597±3.693 m and the minimum value is 7.115 m. The elevation accuracy of flat area is better than 0.3 m, although it is slightly lower than the results of field calibration, it can basically meet the requirements of 1: 10 000 elevation control points. © 2022, Surveying and Mapping Press. All right reserved.

Study of Fourier series of user defined waveforms using ExpEYES-17 kit

This article presents the study of Fourier series experimentally, using the ExpEYES-17 kit in a different way. This familiar undergraduate experiment has been performed for teaching online laboratory classes when face-to-face classes were not possible, due to the COVID - 19 pandemic. We chose parabolic and sawtooth waveforms, which are not generally considered for this experiment. The amplitudes A n of different harmonics were measured to compare with the theoretical predictions and the ratios An/A1 were found to agree well. © 2022 IOP Publishing Ltd.

Respiratory noninvasive venous waveform analysis investigated in chronic pulmonary conditions

INTRODUCTION: Respiratory disease, acute and chronic, can be difficult to diagnose and monitor. To date, there are only two standard non-invasive monitoring approaches for assessing respiratory distress: respiratory rate and SpO2. The Respiratory non-Invasive Venous waveform Analysis (RIVA) was first described in COVID-19 patients as a promising, novel physiological measurement that predicted a COVID-19+ patient's need for oxygen support therapy. The aim of this study was to investigate if this RIVA signal was present in chronic pulmonary conditions. METHODS: Secondary analysis of a venous waveform dataset of human subjects that had pulmonary function tests (PFT) were analyzed to assess how their chronic respiratory illnesses affected the magnitude of their respiratory signal. Data was captured via a non-invasive piezoelectric sensor and analyzed on LabChart 8. Using spectral analysis in 8K windows, the respiratory peak of the signal (low frequency ~0.2 Hz) was measured for magnitude relative to their cardiac peak (higher frequency ~1.0 Hz) to calculate RIVA-RI (respiratory peak/cardiac peak). These values were grouped according to their pulmonary disease and an ANOVA with multiple comparisons was conducted to determine the significance between groups. RESULTS: Healthy control subjects displayed significantly lower RIVA-RI values compared to patients reporting the PFT lab with asthma or idiopathic pulmonary fibrosis (IPF;p < 0.05). Patients with chronic obstructive pulmonary disease, pulmonary hypertension, and/or obstructive sleep apnea did not have significant RIVA-RI values compared to healthy controls. CONCLUSIONS: This novel signal, first discovered in COVID-19+ patients that required oxygen support therapy, is also present in asthmatic and IPF patients. More research is needed to better understand the respiratory venous signal and how it could be used to monitor respiratory disease.

Independent pressure regulation enables safe multi-patient ventilation without adverse interactions

INTRODUCTION/HYPOTHESIS: The ongoing COVID-19 pandemic has severely strained critical care resources worldwide. Although abating in some areas, new variants may cause vaccine-resistant resurgence, and future pandemics have the potential to be even more severe. Ventilator-sharing has the potential to address equipment shortages in time of crisis, but has generated controversy due to concerns over adverse inter-patient interactions. Our objective was to design and test a robust, low-cost ventilator multiplication device that would adequately mitigate these risks, safely augmenting capacity while minimizing burden on staff and infrastructure. METHODS: We developed a novel, streamlined ventilation multiplier that we hypothesized would maintain stable, independent pressure-control parameters for each patient in the face of wide swings in the other. Inspiratory and expiratory pressures are independently adjusted by mechanical controls. Inexpensive electronics deliver monitoring and individualized alarms to provider devices. Two simulated patients were connected to a single mechanical ventilator via the MultiVent device. Perturbations of pressure and compliance in one simulated patient were made, while monitoring the pressure waveform and tidal volume delivered to the paired patient. RESULTS: The device effectively maintained desired pressure-control ventilation parameters to each simulated patient under multiple perturbations. Abrupt changes were made to Patient A, including large changes in compliance as well as adjustments to the pressures prescribed. In all cases, Patient B maintained stable pressures and tidal volumes, with no adjustments needed. Although other ventilator splitters have been reported, this is the first description of an integrated device that independently regulates both inspiratory and expiratory pressure for each patient. In doing so, it enables individualized pressure-control ventilation that is resilient to changes in the lung mechanics and support requirements of paired patients. The device presented here addresses many concerns that have been voiced related to ventilator-sharing. CONCLUSIONS: Supporting multiple patients from a single ventilator may be feasible in times of pandemic respiratory failure or in places with severely constrained resources, when conventional ventilator supplies are inadequate.

Utility of APTT Based CLOT Waveform Parametersin Various Clinical Conditions-A Study at Tertiary Care Center

Introduction: Coagulation tests performed in laboratory are prothrombin time, activated partial thromboplastin time (APTT),thrombin time help in understanding of pathways involved in coagulation, yet they lack information on the complexity of haemostasis.Global coagulation assays like Thromboelastogram, Thrombin Generation Test and Clot waveform analysis (CWA) are point of caretests which provide rapid approach to a clinical condition. Clot waveis an optical waveform which measures changes in transmittance orabsorbance of light beam through sample. Various applications ofCWA have been extensively studied in last few years.Aims &Objectives: To analyze clot wave form characteristics likemorphology, first and second derivative values in cases with abnormalAPTT.Materials &Methods: APTT and curves generated by ACL TOP300 analyzer of total 125 patients and 20 controls were included.Parameters studied were first derivative (maximum velocity of clotformation), second derivatives (maximum acceleration and deceleration), morphology of curve: sigmoid, biphasic, prolonged precoagulation phase, second derivative morphology like early and lateshoulder, biphasic peak, delayed deceleration were noted. MannWhitney U test was performed and p value was determined.Result: The APTT waveforms were analyzed in 125 patients (M: F-2.2:1, mean age: 46.9 ± 20 years). A spectrum of clinical conditionsshowed covid (20%), liver disease (23%), polytrauma (10.4%), cardiac (8.8%), sepsis/DIC (7.2%), thromboembolism (7.2%), renal(6.4%), bacterial infections (4%), dengue (4%), snake bite (1.6%),factor deficiency (1.6%). There was significant difference in acceleration and deceleration peaks in cases of liver and heart disease,sepsis, dengue, polytrauma and sepsis/DIC cases. Deceleration peakwas additionally prolonged in patients of covid (p<0.05). Firstderivative peak was prolonged in only sepsis and liver diseases(p< 0.05). The pre coagulation phase was prolonged in 75 cases(60%) cases and predominantly covid patients along with secondderivative showing delayed deceleration, early and late shoulder.Conclusions: CWA is readily available on automated coagulationanalyzers being inexpensive with fast turn round time. It providesboth quantitative information on coagulation like velocity, acceleration of clot formation and qualitative details of wave pattern. Therewas significant association of second derivative with the disease inour study. Our study highlights importance to probe into quantitativeand qualitative CWA parameters acquired by performing a simpleAPTT test.

On Analyzing Capnogram as a Novel Method for Screening COVID-19: A Review on Assessment Methods for COVID-19.

In November 2019, the novel coronavirus disease COVID-19 was reported in Wuhan city, China, and was reported in other countries around the globe. COVID-19 is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Strategies such as contact tracing and a vaccination program have been imposed to keep COVID-19 under control. Furthermore, a fast, noninvasive and reliable testing device is needed urgently to detect COVID-19, so that contact can be isolated and ringfenced before the virus spreads. Although the reverse transcription polymerase chain reaction (RT-PCR) test is considered the gold standard method for the diagnosis of SARS-CoV-2 infection, this test presents some limitations which cause delays in detecting the disease. The antigen rapid test (ART) test, on the other hand, is faster and cheaper than PCR, but is less sensitive, and may limit SARS-CoV-2 detection. While other tests are being developed, accurate, noninvasive and easy-to-use testing tools are in high demand for the rapid and extensive diagnosis of the disease. Therefore, this paper reviews current diagnostic methods for COVID-19. Following this, we propose the use of expired carbon dioxide (CO2) as an early screening tool for SARS-CoV-2 infection. This system has already been developed and has been tested on asthmatic patients. It has been proven that expired CO2, also known as capnogram, can help differentiate between respiratory conditions and, therefore, could be used to detect SARS-CoV-2 infection, as it causes respiratory tract-related diseases.

Respiratory Non-Invasive Venous Waveform Analysis for Assessment of Respiratory Distress in Coronavirus Disease 2019 Patients: An Observational Study.

OBJECTIVES: Due to the rapid rate of severe acute respiratory syndrome coronavirus 2 transmission and the heterogeneity of symptoms of coronavirus disease 2019, expeditious and effective triage is critical for early treatment and effective allocation of hospital resources. DESIGN: A post hoc analysis of respiratory data from non-invasive venous waveform analysis among patients enrolled in an observational study was performed. SETTING: Vanderbilt University Medical Center. PATIENTS: Peripheral venous waveforms were recorded from admission to discharge in enrolled coronavirus disease 2019-positive patients and healthy age-matched controls. INTERVENTIONS: Data were analyzed in LabChart 8 to transform venous waveforms to the frequency domain using fast Fourier transforms. The peak respiratory frequency was normalized to the peak cardiac frequency to generate a respiratory non-invasive venous waveform analysis respiratory index. Paired Fisher exact tests were used to compare each patient's respiratory non-invasive venous waveform analysis respiratory index at admission and discharge. A nonparametric one-way analysis of variance was used for multiple comparisons between patients with coronavirus disease 2019 and healthy controls for respiratory non-invasive venous waveform analysis respiratory index. MEASUREMENTS AND MAIN RESULTS: Fifty coronavirus disease 2019-positive patients were enrolled between April 2020, and September 2020, and 45 were analyzed; 34 required supplemental oxygen and 11 did not. The respiratory non-invasive venous waveform analysis respiratory index was significantly higher for the 34 patients with coronavirus disease 2019 who received supplemental oxygen (median, 0.27; interquartile range, 0.11-1.28) compared with the 34 healthy controls (median, 0.06; interquartile range, 0.03-0.14) (p < 0.01). For patients with coronavirus disease 2019 who received supplemental oxygen, respiratory non-invasive venous waveform analysis respiratory index was significantly lower at hospital discharge (p = 0.02; 95% CI, 0.10-1.9) compared with hospital admission (median = 0.12; interquartile range, 0.05-0.56). For patients with coronavirus disease 2019, a respiratory non-invasive venous waveform analysis respiratory index of 0.64 demonstrated sensitivity of 92%, specificity of 47%, and positive predictive value of 93% for predicting requirement of supplemental oxygen during the hospitalization. CONCLUSIONS: Respiratory non-invasive venous waveform analysis respiratory index represents a novel physiologic respiratory measurement with a promising ability to triage early care and predict the need for oxygen support therapy in coronavirus disease 2019 patients.