Development of a national maternity early warning score: centile based score development and Delphi informed escalation pathways.

Objective: To derive a new maternity early warning score (MEWS) from prospectively collected data on maternity vital signs and to design clinical response pathways with a Delphi consensus exercise. Design: Centile based score development and Delphi informed escalation pathways. Setting: Pregnancy Physiology Pattern Prediction (4P) prospective UK cohort study, 1 August 2012 to 28 December 2016. Participants: Pregnant people from the 4P study, recruited before 20 weeks' gestation at three UK maternity centres (Oxford, Newcastle, and London). 841, 998, and 889 women provided data in the early antenatal, antenatal, and postnatal periods. Main outcome measures: Development of a new national MEWS, assigning numerical weights to measurements in the lower and upper extremes of distributions of individual vital signs from the 4P prospective cohort study. Comparison of escalation rates of the new national MEWS with the Scottish and Irish MEWS systems from 18 to 40 weeks' gestation. Delphi consensus exercise to agree clinical responses to raised scores. Results: A new national MEWS was developed by assigning numerical weights to measurements in the lower and upper extremes (5%, 1%) of distributions of vital signs, except for oxygen saturation where lower centiles (10%, 2%) were used. For the new national MEWS, in a healthy population, 56% of observation sets resulted in a total score of 0 points, 26% a score of 1 point, 12% a score of 2 points, and 18% a score of ≥2 points (escalation of care is triggered at a total score of ≥2 points). Corresponding values for the Irish MEWS were 37%, 25%, 22%, and 38%, respectively; and for the Scottish MEWS, 50%, 18%, 21%, and 32%, respectively. All three MEWS were similar at the beginning of pregnancy, averaging 0.7-0.9 points. The new national MEWS had a lower mean score for the rest of pregnancy, with the mean score broadly constant (0.6-0.8 points). The new national MEWS had an even distribution of healthy population alerts across the antenatal period. In the postnatal period, heart rate threshold values were adjusted to align with postnatal changes. The centile based score derivation approach meant that each vital sign component in the new national MEWS had a similar alert rate. Suggested clinical responses to different MEWS values were agreed by consensus of an independent expert panel. Conclusions: The centile based MEWS alerted escalation of care evenly across the antenatal period in a healthy population, while reducing alerts in healthy women compared with other MEWS systems. How well the tool predicted adverse outcomes, however, was not assessed and therefore external validation studies in large datasets are needed. Unlike other MEWS systems, the new national MEWS was developed with prospectively collected data on vital signs and used a systematic, expert informed process to design an associated escalation protocol.

Multivariable prediction models for atrial fibrillation after cardiac surgery: a systematic review protocol.

INTRODUCTION: Dozens of multivariable prediction models for atrial fibrillation after cardiac surgery (AFACS) have been published, but none have been incorporated into regular clinical practice. One of the reasons for this lack of adoption is poor model performance due to methodological weaknesses in model development. In addition, there has been little external validation of these existing models to evaluate their reproducibility and transportability. The aim of this systematic review is to critically appraise the methodology and risk of bias of papers presenting the development and/or validation of models for AFACS. METHODS: We will identify studies that present the development and/or validation of a multivariable prediction model for AFACS through searches of PubMed, Embase and Web of Science from inception to 31 December 2021. Pairs of reviewers will independently extract model performance measures, assess methodological quality and assess risk of bias of included studies using extraction forms adapted from a combination of the Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies checklist and the Prediction Model Risk of Bias Assessment Tool. Extracted information will be reported by narrative synthesis and descriptive statistics. ETHICS AND DISSEMINATION: This systemic review will only include published aggregate data, so no protected health information will be used. Study findings will be disseminated through peer-reviewed publications and scientific conference presentations. Further, this review will identify weaknesses in past AFACS prediction model development and validation methodology so that subsequent studies can improve upon prior practices and produce a clinically useful risk estimation tool. PROSPERO REGISTRATION NUMBER: CRD42019127329.

Increased long-term mortality following new-onset atrial fibrillation in the intensive care unit: A systematic review and meta-analysis.

PURPOSE: We performed a systematic review and meta-analysis to investigate the long-term outcomes of patients who develop new-onset atrial fibrillation (NOAF) during an intensive care unit (ICU) admission. METHODS: We searched the MEDLINE and EMBASE databases from 2000 to 2022. We included studies of adults based in general ICUs that evaluated long-term outcomes (at least 30 days after hospital discharge) of NOAF. We excluded studies involving patients with a history of atrial fibrillation (AF). We performed risk of bias assessment of the included studies based on a modified Newcastle Ottawa score (NOS). We extracted summary data for long-term outcomes. Where the outcome was reported in three or more studies we pooled effect sizes. RESULTS: We screened 2206 studies and included 15 studies reporting data from 561,797 patients. Pooled analysis of 4 studies using a random effects model revealed an association between NOAF acquired in an ICU and 90-day mortality (including ICU and hospital mortality) (RR 1.53, 95% CI 1.12-2.08). We also found an association between NOAF and 1-year mortality from 7 studies (RR 1.79, 95% CI 1.65-1.96), which remained when analysing 1-year mortality in hospital survivors (RR 1.72 (95% CI 1.49-1.98). CONCLUSIONS: In patients who develop NOAF in an ICU, both 90-day and 1-year mortality are increased in comparison to those who do not develop NOAF. Current evidence suggests an increased risk of thromboembolic events after hospital discharge in patients who develop NOAF in an ICU.

New-onset atrial fibrillation in intensive care: epidemiology and outcomes.

AIMS: New-onset atrial fibrillation (NOAF) is common in patients treated on an intensive care unit (ICU), but the long-term impacts on patient outcomes are unclear. We compared national hospital and long-term outcomes of patients who developed NOAF in ICU with those who did not, before and after adjusting for comorbidities and ICU admission factors. METHODS AND RESULTS: Using the RISK-II database (Case Mix Programme national clinical audit of adult intensive care linked with Hospital Episode Statistics and mortality data), we conducted a retrospective cohort study of 4615 patients with NOAF and 27 690 matched controls admitted to 248 adult ICUs in England, from April 2009 to March 2016. We examined in-hospital mortality; hospital readmission with atrial fibrillation (AF), heart failure, and stroke up to 6 years post discharge; and mortality up to 8 years post discharge. Compared with controls, patients who developed NOAF in the ICU were at a higher risk of in-hospital mortality [unadjusted odds ratio (OR) 3.22, 95% confidence interval (CI) 3.02-3.44], only partially explained by patient demographics, comorbidities, and ICU admission factors (adjusted OR 1.50, 95% CI 1.38-1.63). They were also at a higher risk of subsequent hospitalization with AF [adjusted cause-specific hazard ratio (aCHR) 5.86, 95% CI 5.33-6.44], stroke (aCHR 1.47, 95% CI 1.12-1.93), and heart failure (aCHR 1.28, 95% CI 1.14-1.44) independent of pre-existing comorbidities. CONCLUSION: Patients who develop NOAF during an ICU admission are at a higher risk of in-hospital death and readmissions to hospital with AF, heart failure, and stroke than those who do not.

Circadian variation in new-onset atrial fibrillation in patients in ICUs.

New-onset atrial fibrillation (NOAF) is common in patients treated on an intensive care unit (ICU). Onset of certain arrhythmias exhibit circadian variation. Whether NOAF follows a circadian rhythm in patients in ICU is unknown. We undertook a retrospective observational study of two ICU databases to explore the timing of NOAF onset. We identified 2017 patients who developed NOAF during their ICU stay. NOAF onset exhibited a bimodal distribution with peaks at 8 am and 8 pm, consistent with the onset of paroxysmal AF in patients in the community. Future studies in ICUs should record time of AF onset, as understanding high risk periods may inform timing of preventative interventions.

Comparative effectiveness of common treatments for new-onset atrial fibrillation within the ICU: Accounting for physiological status.

BACKGROUND: New-onset atrial fibrillation (NOAF) is common in patients on an intensive care unit (ICU). Evidence guiding treatments is limited, though recent reports suggest beta blocker (BB) therapy is associated with reduced mortality. METHODS: We conducted a multicentre cohort study of adult patients admitted to 3 ICUs in the UK and 5 ICUs in the USA. We analysed the haemodynamic changes associated with NOAF. We analysed rate control, rhythm control, and hospital mortality associated with common NOAF treatments. We balanced admission and post-NOAF, pre-treatment covariates across treatment groups. RESULTS: NOAF was followed by a systolic blood pressure reduction of 5 mmHg (p < 0.001). After adjustment, digoxin therapy was associated with inferior rate control versus amiodarone (adjusted hazard ratio (aHR) 0.56, [95% CI 0.34-0.92]). Calcium channel blocker (CCB) therapy was associated with inferior rhythm control versus amiodarone (aHR 0.59 (0.37-0.92). No difference was detected between BBs and amiodarone in rate control (aHR 1.15 [0.91-1.46]), rhythm control (aHR 0.85, [0.69-1.05]), or hospital mortality (aHR 1.03 [0.53-2.03]). CONCLUSIONS: NOAF in ICU patients is followed by decreases in blood pressure. BBs and amiodarone are associated with similar cardiovascular control and appear superior to digoxin and CCBs. Accounting for key confounders removes previously reported mortality benefits associated with BB treatment.

Risk factors for new-onset atrial fibrillation during critical illness: A Delphi study.

Background: New-onset atrial fibrillation (NOAF) is common during critical illness and is associated with poor outcomes. Many risk factors for NOAF during critical illness have been identified, overlapping with risk factors for atrial fibrillation in patients in community settings. To develop interventions to prevent NOAF during critical illness, modifiable risk factors must be identified. These have not been studied in detail and it is not clear which variables warrant further study. Methods: We undertook an international three-round Delphi process using an expert panel to identify important predictors of NOAF risk during critical illness. Results: Of 22 experts invited, 12 agreed to participate. Participants were located in Europe, North America and South America and shared 110 publications on the subject of atrial fibrillation. All 12 completed the three Delphi rounds. Potentially modifiable risk factors identified include 15 intervention-related variables. Conclusions: We present the results of the first Delphi process to identify important predictors of NOAF risk during critical illness. These results support further research into modifiable risk factors including optimal plasma electrolyte concentrations, rates of change of these electrolytes, fluid balance, choice of vasoactive medications and the use of preventative medications in high-risk patients. We also hope our findings will aid the development of predictive models for NOAF.

Pharmacological and non-pharmacological treatments and outcomes for new-onset atrial fibrillation in ICU patients: the CAFE scoping review and database analyses.

BACKGROUND: New-onset atrial fibrillation occurs in around 10% of adults treated in an intensive care unit. New-onset atrial fibrillation may lead to cardiovascular instability and thromboembolism, and has been independently associated with increased length of hospital stay and mortality. The long-term consequences are unclear. Current practice guidance is based on patients outside the intensive care unit; however, new-onset atrial fibrillation that develops while in an intensive care unit differs in its causes and the risks and clinical effectiveness of treatments. The lack of evidence on new-onset atrial fibrillation treatment or long-term outcomes in intensive care units means that practice varies. Identifying optimal treatment strategies and defining long-term outcomes are critical to improving care. OBJECTIVES: In patients treated in an intensive care unit, the objectives were to (1) evaluate existing evidence for the clinical effectiveness and safety of pharmacological and non-pharmacological new-onset atrial fibrillation treatments, (2) compare the use and clinical effectiveness of pharmacological and non-pharmacological new-onset atrial fibrillation treatments, and (3) determine outcomes associated with new-onset atrial fibrillation. METHODS: We undertook a scoping review that included studies of interventions for treatment or prevention of new-onset atrial fibrillation involving adults in general intensive care units. To investigate the long-term outcomes associated with new-onset atrial fibrillation, we carried out a retrospective cohort study using English national intensive care audit data linked to national hospital episode and outcome data. To analyse the clinical effectiveness of different new-onset atrial fibrillation treatments, we undertook a retrospective cohort study of two large intensive care unit databases in the USA and the UK. RESULTS: Existing evidence was generally of low quality, with limited data suggesting that beta-blockers might be more effective than amiodarone for converting new-onset atrial fibrillation to sinus rhythm and for reducing mortality. Using linked audit data, we showed that patients developing new-onset atrial fibrillation have more comorbidities than those who do not. After controlling for these differences, patients with new-onset atrial fibrillation had substantially higher mortality in hospital and during the first 90 days after discharge (adjusted odds ratio 2.32, 95% confidence interval 2.16 to 2.48; adjusted hazard ratio 1.46, 95% confidence interval 1.26 to 1.70, respectively), and higher rates of subsequent hospitalisation with atrial fibrillation, stroke and heart failure (adjusted cause-specific hazard ratio 5.86, 95% confidence interval 5.33 to 6.44; adjusted cause-specific hazard ratio 1.47, 95% confidence interval 1.12 to 1.93; and adjusted cause-specific hazard ratio 1.28, 95% confidence interval 1.14 to 1.44, respectively), than patients who did not have new-onset atrial fibrillation. From intensive care unit data, we found that new-onset atrial fibrillation occurred in 952 out of 8367 (11.4%) UK and 1065 out of 18,559 (5.7%) US intensive care unit patients in our study. The median time to onset of new-onset atrial fibrillation in patients who received treatment was 40 hours, with a median duration of 14.4 hours. The clinical characteristics of patients developing new-onset atrial fibrillation were similar in both databases. New-onset atrial fibrillation was associated with significant average reductions in systolic blood pressure of 5 mmHg, despite significant increases in vasoactive medication (vasoactive-inotropic score increase of 2.3; p < 0.001). After adjustment, intravenous beta-blockers were not more effective than amiodarone in achieving rate control (adjusted hazard ratio 1.14, 95% confidence interval 0.91 to 1.44) or rhythm control (adjusted hazard ratio 0.86, 95% confidence interval 0.67 to 1.11). Digoxin therapy was associated with a lower probability of achieving rate control (adjusted hazard ratio 0.52, 95% confidence interval 0.32 to 0.86) and calcium channel blocker therapy was associated with a lower probability of achieving rhythm control (adjusted hazard ratio 0.56, 95% confidence interval 0.39 to 0.79) than amiodarone. Findings were consistent across both the combined and the individual database analyses. CONCLUSIONS: Existing evidence for new-onset atrial fibrillation management in intensive care unit patients is limited. New-onset atrial fibrillation in these patients is common and is associated with significant short- and long-term complications. Beta-blockers and amiodarone appear to be similarly effective in achieving cardiovascular control, but digoxin and calcium channel blockers appear to be inferior. FUTURE WORK: Our findings suggest that a randomised controlled trial of amiodarone and beta-blockers for management of new-onset atrial fibrillation in critically ill patients should be undertaken. Studies should also be undertaken to provide evidence for or against anticoagulation for patients who develop new-onset atrial fibrillation in intensive care units. Finally, given that readmission with heart failure and thromboembolism increases following an episode of new-onset atrial fibrillation while in an intensive care unit, a prospective cohort study to demonstrate the incidence of atrial fibrillation and/or left ventricular dysfunction at hospital discharge and at 3 months following the development of new-onset atrial fibrillation should be undertaken. TRIAL REGISTRATION: Current Controlled Trials ISRCTN13252515. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 71. See the NIHR Journals Library website for further project information.

BACKGROUND: Atrial fibrillation can cause heart failure and stroke. It can also affect heart rate in different ways. It is common for patients admitted to intensive care units to develop atrial fibrillation. When patients have never had atrial fibrillation before, this is called 'new-onset atrial fibrillation'. We do not know how new-onset atrial fibrillation in patients treated in an intensive care unit affects heart rate and blood pressure, what the best treatments are or how treatments affect how people recover. METHODS: We looked at studies of new-onset atrial fibrillation treatments in intensive care units to see if some treatments have been shown to work better. We used a national database to see what happens to intensive care unit patients in the UK who develop new-onset atrial fibrillation. We also used two databases from intensive care units in the UK and the USA to see how many patients in the intensive care units have new-onset atrial fibrillation, how atrial fibrillation affects heart rate and blood pressure, and whether or not some treatments work better than others. RESULTS: Between 6% and 11% of intensive care unit patients develop new-onset atrial fibrillation. These patients are more likely to die in hospital and in the first 90 days after discharge than those who do not. They are also more likely to be readmitted to hospital with atrial fibrillation, stroke and heart failure. The evidence for new-onset atrial fibrillation treatments is limited, but suggests that beta-blockers or amiodarone may work better than calcium channel blockers or digoxin. CONCLUSIONS: New-onset atrial fibrillation in intensive care units is common, and outcomes are worse in patients who develop new-onset atrial fibrillation than in those who do not. Our research shows that some new-onset atrial fibrillation treatments work better than others. This information will help us to plan a study to improve health after new-onset atrial fibrillation.

Treatment strategies for new onset atrial fibrillation in patients treated on an intensive care unit: a systematic scoping review.

BACKGROUND: New-onset atrial fibrillation (NOAF) in patients treated on an intensive care unit (ICU) is common and associated with significant morbidity and mortality. We undertook a systematic scoping review to summarise comparative evidence to inform NOAF management for patients admitted to ICU. METHODS: We searched MEDLINE, EMBASE, CINAHL, Web of Science, OpenGrey, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, ISRCTN, ClinicalTrials.gov, EU Clinical Trials register, additional WHO ICTRP trial databases, and NIHR Clinical Trials Gateway in March 2019. We included studies evaluating treatment or prevention strategies for NOAF or acute anticoagulation in general medical, surgical or mixed adult ICUs. We extracted study details, population characteristics, intervention and comparator(s), methods addressing confounding, results, and recommendations for future research onto study-specific forms. RESULTS: Of 3,651 citations, 42 articles were eligible: 25 primary studies, 12 review articles and 5 surveys/opinion papers. Definitions of NOAF varied between NOAF lasting 30 s to NOAF lasting > 24 h. Only one comparative study investigated effects of anticoagulation. Evidence from small RCTs suggests calcium channel blockers (CCBs) result in slower rhythm control than beta blockers (1 study), and more cardiovascular instability than amiodarone (1 study). Evidence from 4 non-randomised studies suggests beta blocker and amiodarone therapy may be equivalent in respect to rhythm control. Beta blockers may be associated with improved survival compared to amiodarone, CCBs, and digoxin, though supporting evidence is subject to confounding. Currently, the limited evidence does not support therapeutic anticoagulation during ICU admission. CONCLUSIONS: From the limited evidence available beta blockers or amiodarone may be superior to CCBs as first line therapy in undifferentiated patients in ICU. The little evidence available does not support therapeutic anticoagulation for NOAF whilst patients are critically ill. Consensus definitions for NOAF, rate and rhythm control are needed.

Hospital outcomes associated with new-onset atrial fibrillation during ICU admission: A multicentre competing risks analysis.

PURPOSE: New onset atrial fibrillation (NOAF) in critically ill patients has been associated with increased short-term mortality. Analyses that do not take into account the time-varying nature of NOAF can underestimate its association with hospital outcomes. We investigated the prognostic association of NOAF with hospital outcomes using competing risks methods. MATERIALS AND METHODS: We undertook a retrospective cohort study in three general adult intensive care units (ICUs) in the UK from June 2008 to December 2015. We excluded patients with known prior atrial fibrillation or an arrhythmia within four hours of ICU admission. To account for the effect of NOAF on the rate of death per unit time and the rate of discharge alive per unit time we calculated subdistribution hazard ratios (SDHRs). RESULTS: Of 7541 patients that fulfilled our inclusion criteria, 831 (11.0%) developed NOAF during their ICU admission. NOAF was associated with an increased duration of hospital stay (CSHR 0.68 (95% CI 0.63-0.73)) and an increased rate of in-hospital death per unit time (CSHR 1.57 (95% CI 1.37-1.1.81)). This resulted in a strong prognostic association with dying in hospital (adjusted SDHR 2.04 (1.79-2.32)). NOAF lasting over 30 min was associated with increased hospital mortality. CONCLUSIONS: Using robust methods we demonstrate a stronger prognostic association between NOAF and hospital outcomes than previously reported.

Months-long thousand-kilometre-scale wobbling before great subduction earthquakes.

Megathrust earthquakes are responsible for some of the most devastating natural disasters1. To better understand the physical mechanisms of earthquake generation, subduction zones worldwide are continuously monitored with geophysical instrumentation. One key strategy is to install stations that record signals from Global Navigation Satellite Systems2,3 (GNSS), enabling us to track the non-steady surface motion of the subducting and overriding plates before, during and after the largest events4-6. Here we use a recently developed trajectory modelling approach7 that is designed to isolate secular tectonic motions from the daily GNSS time series to show that the 2010 Maule, Chile (moment magnitude 8.8) and 2011 Tohoku-oki, Japan (moment magnitude 9.0) earthquakes were preceded by reversals of 4-8 millimetres in surface displacement that lasted several months and spanned thousands of kilometres. Modelling of the surface displacement reversal that occurred before the Tohoku-oki earthquake suggests an initial slow slip followed by a sudden pulldown of the Philippine Sea slab so rapid that it caused a viscoelastic rebound across the whole of Japan. Therefore, to understand better when large earthquakes are imminent, we must consider not only the evolution of plate interface frictional processes but also the dynamic boundary conditions from deeper subduction processes, such as sudden densification of metastable slab.

Managing new-onset atrial fibrillation in critically ill patients: a systematic narrative review.

OBJECTIVES: The aim of this review is to summarise the latest evidence on efficacy and safety of treatments for new-onset atrial fibrillation (NOAF) in critical illness. PARTICIPANTS: Critically ill adult patients who developed NOAF during admission. PRIMARY AND SECONDARY OUTCOMES: Primary outcomes were efficacy in achieving rate or rhythm control, as defined in each study. Secondary outcomes included mortality, stroke, bleeding and adverse events. METHODS: We searched MEDLINE, EMBASE and Web of Knowledge on 11 March 2019 to identify randomised controlled trials (RCTs) and observational studies reporting treatment efficacy for NOAF in critically ill patients. Data were extracted, and quality assessment was performed using the Cochrane Risk of Bias Tool, and an adapted Newcastle-Ottawa Scale. RESULTS: Of 1406 studies identified, 16 remained after full-text screening including two RCTs. Study quality was generally low due to a lack of randomisation, absence of blinding and small cohorts. Amiodarone was the most commonly studied agent (10 studies), followed by beta-blockers (8), calcium channel blockers (6) and magnesium (3). Rates of successful rhythm control using amiodarone varied from 30.0% to 95.2%, beta-blockers from 31.8% to 92.3%, calcium channel blockers from 30.0% to 87.1% and magnesium from 55.2% to 77.8%. Adverse effects of treatment were rarely reported (five studies). CONCLUSION: The reported efficacy of beta-blockers, calcium channel blockers, magnesium and amiodarone for achieving rhythm control was highly varied. As there is currently significant variation in how NOAF is managed in critically ill patients, we recommend future research focuses on comparing the efficacy and safety of amiodarone, beta-blockers and magnesium. Further research is needed to inform the decision surrounding anticoagulant use in this patient group.

Prophylactic use of platelets in critically ill patients with thrombocytopaenia: A retrospective two-centre observational study.

PURPOSE: We report the use and effect of prophylactic platelet transfusions in critically ill thrombocytopaenic patients, comparing patients with or without bone marrow failure as a cause of thrombocytopaenia. METHODS: A retrospective observational study of admissions to three intensive care units (ICU) in the UK. We identified thrombocytopaenic patients who received a platelet transfusion and extracted the platelet count prior and subsequent to platelet transfusion. We grouped patients with or without suspected bone marrow failure, defined by a total white cell count ≤1.0 × 109/L. RESULTS: Of 11,757 admissions, 399 (3.4%) patients received a platelet transfusion for thrombocytopaenia. The median [IQR] platelet count prior to transfusion in patients without bone marrow failure was 42 [28-64] × 109/L versus 14 [7-24] × 109/L (p < .0001) in those with. The median [IQR] increment in platelets following transfusion was lower in patients with marrow failure (12 [-1-23] × 109/L) compared to those without (18 [5-36] × 109/L) (p = .006). CONCLUSIONS: Platelet transfusions were given at a higher median platelet count than suggested by guidelines. Patients with bone marrow failure were transfused at a lower threshold and experienced a smaller increment in platelet count when compared to patients without marrow failure.

Risk factors for new-onset atrial fibrillation on the general adult ICU: A systematic review.

PURPOSE: This study was performed to systematically review the available evidence for the risk factors for new-onset atrial fibrillation (NOAF) on the general adult intensive care unit (ICU) and provide a semi-quantitative evidence synthesis. METHODS: We searched the MEDLINE, EMBASE, Cochrane Database of Systematic Reviews and the CENTRAL databases from 1970 to 2018. We included studies of adults based in general ICUs that evaluated potential risk factors for NOAF. We excluded studies involving patients with a history of atrial fibrillation (AF). We semi-qualitatively evaluated the strength of evidence for each identified variable. RESULTS: We screened 1447 studies. Seventeen studies were included in the final analysis. We identified strong evidence for age, male sex, preceding cardiovascular disease, acute renal failure, acute respiratory failure, APACHE score and the use of vasopressors as risk factors for the development of NOAF on the ICU. Modifiable risk factors had not been studied in detail. CONCLUSIONS: We provide the first systematic review with evidence synthesis of risk factors for NOAF on the general adult ICU. Evidence for modifiable risk factors was limited. Further research is therefore required and may contribute towards the evidence-based prevention and management of this important condition.

Risk factors for new-onset atrial fibrillation on the general adult ICU: protocol for a systematic review.

INTRODUCTION: Atrial fibrillation (AF) is a common arrhythmia in the critical care environment. New-onset AF is associated with increased mortality and intensive care unit (ICU) length of stay. Observational studies have identified several epidemiological and disease severity-related factors associated with developing new-onset AF on the ICU. However, there are limited data on the modifiable risk factors in the general adult ICU population.We describe a protocol for a systematic review of modifiable and non-modifiable risk factors for new-onset AF in the general adult ICU population. The results of this review will aid the development of risk prediction tools and inform future research into AF prevention on the ICU. METHODS AND ANALYSIS: Medical Literature Analysis and Retrieval System Online, Excerpta Medica database and the Cochrane Library, including Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials will be searched for studies that assess the association of patient variables, investigation results, interventions and diagnoses associated with subsequent new-onset AF on the ICU.Only studies involving adult patients admitted to non-service-specific ICUs will be included. We will extract data relating to the statistical association between reversible and non-reversible factors and AF, the quality of the studies and the generalisability of the results. This systematic review will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. ETHICS AND DISSEMINATION: This proposed systematic review will be based on published data, and therefore ethical approval is not required. The findings of this study will be disseminated through publication in a peer reviewed journal and will be presented at conferences. PROSPERO REGISTRATION NUMBER: CRD42017074221.

Bridging the logistical gap between ultrasound enthusiasm and accreditation.

Point-of-care ultrasound is increasingly recognised as a valuable adjunct to patient care. Trainees in intensive care medicine are expected to accredit in focused intensive care echocardiography, but the availability of trained mentors and logistical/geographical factors make this difficult within the time constraints required. As a result, many trainees who are enthusiastic about point-of-care ultrasound find it difficult to achieve accreditation. We present a secure, web-based, multi-user system which mitigates many of these difficulties and allows for clinical mentorship to take place without geographical barriers, and at a time convenient for the participants.

Gradual unlocking of plate boundary controlled initiation of the 2014 Iquique earthquake.

On 1 April 2014, Northern Chile was struck by a magnitude 8.1 earthquake following a protracted series of foreshocks. The Integrated Plate Boundary Observatory Chile monitored the entire sequence of events, providing unprecedented resolution of the build-up to the main event and its rupture evolution. Here we show that the Iquique earthquake broke a central fraction of the so-called northern Chile seismic gap, the last major segment of the South American plate boundary that had not ruptured in the past century. Since July 2013 three seismic clusters, each lasting a few weeks, hit this part of the plate boundary with earthquakes of increasing peak magnitudes. Starting with the second cluster, geodetic observations show surface displacements that can be associated with slip on the plate interface. These seismic clusters and their slip transients occupied a part of the plate interface that was transitional between a fully locked and a creeping portion. Leading up to this earthquake, the b value of the foreshocks gradually decreased during the years before the earthquake, reversing its trend a few days before the Iquique earthquake. The mainshock finally nucleated at the northern end of the foreshock area, which skirted a locked patch, and ruptured mainly downdip towards higher locking. Peak slip was attained immediately downdip of the foreshock region and at the margin of the locked patch. We conclude that gradual weakening of the central part of the seismic gap accentuated by the foreshock activity in a zone of intermediate seismic coupling was instrumental in causing final failure, distinguishing the Iquique earthquake from most great earthquakes. Finally, only one-third of the gap was broken and the remaining locked segments now pose a significant, increased seismic hazard with the potential to host an earthquake with a magnitude of >8.5.