Pre-hospital ECPR in an Australian metropolitan setting: a single-arm feasibility assessment-The CPR, pre-hospital ECPR and early reperfusion (CHEER3) study.

INTRODUCTION: Survival from refractory out of hospital cardiac arrest (OHCA) without timely return of spontaneous circulation (ROSC) utilising conventional advanced cardiac life support (ACLS) therapies is dismal. CHEER3 was a safety and feasibility study of pre-hospital deployed extracorporeal membrane oxygenation (ECMO) during cardiopulmonary resuscitation (ECPR) for refractory OHCA in metropolitan Australia. METHODS: This was a single jurisdiction, single-arm feasibility study. Physicians, with pre-existing ECMO expertise, responded to witnessed OHCA, age < 65 yrs, within 30 min driving-time, using an ECMO equipped rapid response vehicle. If pre-hospital ECPR was undertaken, patients were transported to hospital for investigations and therapies including emergent coronary catheterisation, and standard intensive care (ICU) therapy until either cardiac and neurological recovery or palliation occurred. Analyses were descriptive. RESULTS: From February 2020 to May 2023, over 117 days, the team responded to 709 "potential cardiac arrest" emergency calls. 358 were confirmed OHCA. Time from emergency call to scene arrival was 27 min (15-37 min). 10 patients fulfilled the pre-defined inclusion criteria and all were successfully cannulated on scene. Time from emergency call to ECMO initiation was 50 min (35-62 min). Time from decision to ECMO support was 16 min (11-26 min). CPR duration was 46 min (32-62 min). All 10 patients were transferred to hospital for investigations and therapy. 4 patients (40%) survived to hospital discharge neurologically intact (CPC 1/2). CONCLUSION: Pre-hospital ECPR was feasible, using an experienced ECMO team from a single-centre. Overall survival was promising in this highly selected group. Further prospective studies are now warranted.

Family experiences and perceptions of intensive care unit care and communication during the COVID-19 pandemic.

INTRODUCTION: In 2020, during the first wave of the COVID-19 pandemic in Melbourne, visitor access to acute hospitals including intensive care units (ICUs) was initially barred, followed by a limit of one person per patient for one hour per day. This study explores the care and communication experienced by family members of ICU patients during this time. METHODS: This qualitative descriptive study was conducted at an Australian quaternary hospital. Semistructured phone interviews were conducted using an aide-memoire designed to understand participants' experiences as family of a patient during this time. Interviews were recorded, transcribed, and thematically analysed. FINDINGS: Twenty family members of patients in the ICU participated. Three major themes were identified: 'impact of restricting visiting procedures', 'family experiences of communication', and 'care and support'. Inflexible visiting restrictions had a momentous impact on families. Participants objected to having to nominate only two people to visit during the admission and the short visiting time limit. Some family members suffered extreme stress and anxiety during their absence from the bedside. Additional challenges were experienced by rural families, visitors with disabilities, and the young children of patients who were excluded. Communication with clinicians varied. Telehealth was valued by some but not universally embraced. The relationship between staff members and families and involvement in decision-making were unaffected. CONCLUSION: Families experienced significant psychological distress from being separated from their critically ill relatives. Patient care and involvement in decision-making appeared to be unchanged, but communication with staff felt to be lacking. Better alternatives to face-to-face communication must be sought to limit the impact of family separation on mental health. Families are a key link between the patient and clinicians and often play a major role in patient support and recovery after discharge. There is an urgent need to support them and facilitate meaningful engagement despite the obstacles.

Deteriorating patients managed with end-of-life care following Medical Emergency Team calls.

AIM: To describe the characteristics of patients whose end-of-life care was initiated in response to a Medical Emergency Team (MET) call and to develop a predictive score to aid prospective identification of these patients. METHODS: Retrospective cohort study of all MET calls in a tertiary teaching hospital between April 2010 and March 2011. All inpatients attended by the hospital MET. The main outcome measures were patient demographics, admission features and comorbidities in active and palliative patients, timing, frequency, physiology, and interventions in active and palliative MET calls. RESULTS: One thousand, five hundred and sixty-seven MET calls were called for 1073 patients. Sixty (5.6%) patients had at least one MET call resulting in initiation of end-of-life care. Palliative MET call patients compared with active patients were older (76.4 vs 65.9 years; P < 0.0001), had a shorter hospital stay (7.5 vs 12 days; P = 0.0002), had increased in-hospital mortality (73.3% vs 13.5%; P < 0.001), had higher Charlson comorbidity scores (3.1 vs 2.1; P = 0.0002) and were more likely to receive multiple MET calls (1.95/patient vs 1.43/patient; P = 0.011). Patient physiological parameters were worse at palliative MET calls. Prior history of malignancy, hemiplegia and peripheral vascular disease, and increasing age were independently associated with initiation of end-of-life care and were used to derive a 13-point predictive score. Patients with a score of 7 or more had a 20% chance of having a palliative MET call. CONCLUSION: Prospective identification of patients requiring palliative care may be possible prior to MET involvement. This may allow more timely and appropriate end-of-life discussions.

Large-scale, decelerating, relativistic x-ray jets from the microquasar XTE J1550-564.

We have detected, at x-ray and radio wavelengths, large-scale moving jets from the microquasar XTE J1550-564. Plasma ejected from near the black hole traveled at relativistic velocities for at least 4 years. We present direct evidence for gradual deceleration in a relativistic jet. The broadband spectrum of the jets is consistent with synchrotron emission from high-energy (up to 10 tera-electron volts) particles that were accelerated in the shock waves formed within the relativistic ejecta or by the interaction of the jets with the interstellar medium. XTE J1550-564 offers a rare opportunity to study the dynamical evolution of relativistic jets on time scales inaccessible for active galactic nuclei jets, with implications for our understanding of relativistic jets from Galactic x-ray binaries and active galactic nuclei.

[Clinical relationship between Chagas' disease and primary arterial hypertension at an outpatient referral service]. / Interação clínica entre moléstia de Chagas e hipertensão arterial primária em um serviço de referência ambulatorial.

PURPOSE: To evaluate the clinical relationship between Chagas' disease and primary arterial hypertension. METHODS: The study involved 878 chronic chagasic outpatients followed by the Chagas' Disease Study Group of the University Hospital (Unicamp), over a 15-year period. Initially, the age, gender, race, clinical form of Chagas' disease and the presence of hypertension were noted for each patient. Subsequently, the data for matched hypertensive and normotensive chagasic patients were compared. RESULTS: Of the chagasic patients 37% were hypertensive, of those, 65% had some form of heart disease compared to 49% in the normotensive group. Of those patients with Chagas' disease and arterial hypertension, 41% were blacks and 35% were caucasians. Fifty percent of the hypertensive chagasic patients were over 45 years old compared to only 29% of the non-hypertensive patients. CONCLUSION: Most of the hypertensive chagasic patients were 45 or more years old and showed some degree of heart failure compared to the normotensive group.

Particulate titanium and cobalt-chrome metallic debris in failed total knee arthroplasty. A quantitative histologic analysis.

Histologic examination of synovial tissue from the revisions of six cobalt-chrome and six titanium alloy total knee arthroplasties was made. Aseptic polyethylene wear-through had resulted in metal-on-metal contact of bearing surfaces and was the primary indication for revision surgery in all knees. The cobalt-chrome alloy prostheses failed at the femorotibial articulation at a mean of 92 months, while the titanium prostheses experienced patellofemoral failure at a mean of 39 months after implantation. Neither alloy was associated with any meaningful inflammatory infiltrate, and cement debris was comparable in both groups. Titanium alloy knees generated significantly more metallic debris than the cobalt-chrome alloy knees (P < .001). Cobalt-chrome alloy knees had more polyethylene debris (P < .01) and a greater number of histiocytes (P < .005). Titanium and polyethylene debris were associated with a prominent giant cell reaction. Titanium exhibited greater abrasive wear and elicited a different cellular response than cobalt-chrome under conditions of polyethylene failure allowing metal-on-metal contact. The variability of this foreign body reaction may be due to important differences in particle size and number, as well as in the material properties of the two alloys.

Color Doppler ultrasound compared to a radionuclide scanning of spermatic cord torsion in a canine model.

High resolution color doppler ultrasound can simultaneously display blood flow superimposed on detailed gray scale anatomic images. Using a single-blind study design, nine adult male dogs underwent intravaginal spermatic cord torsion and subsequent evaluation with technetium 99M-pertechnetate radionuclide, and color doppler ultrasound imaging techniques. Torsions of 90 to 720 degrees were created surgically, followed by examination with each modality at one hour (four animals), and four hours (five animals) following the procedure. Testicular torsion was diagnosed if perfusion was absent or markedly diminished on color doppler imaging or radionuclide scan. In all cases of 360 degrees or greater, torsion was diagnosed by either modality at both one and four hour time delays. If observers did not diagnose torsion, they were asked to assess the relative testicular perfusion. Color doppler ultrasound and radionuclide scanning were without error in correctly detecting a relative decrease in perfusion in each of these instances. Furthermore, color doppler imaging with spectral analysis was able to detect an enhancement of the diastolic component of the arterial signal at 180 degrees of torsion. This spectral pattern coupled with a relative decrease in blood flow allowed presumptive diagnosis at one hour of partial torsion that was subsequently apparent as absent perfusion only after 4 hours on radionuclide and repeat color doppler ultrasound. Color doppler ultrasound proved to be superior to radionuclide scanning in detecting diminished perfusion in this experiment. The detailed information provided by spectral and anatomic display with color doppler ultrasound recommends it for the evaluation of acute scrotal pathology of uncertain etiology.

Systemic cytomegalovirus in a patient with the keratitis, ichthyosis, and deafness (KID) syndrome.

We describe a patient with the keratitis, ichthyosis, and deafness (KID) syndrome who also had a generalized cytomegalovirus infection. Patients with the KID syndrome are susceptible to not only bacterial and fungal infections, but also to viral infections.