Characterizing the impact of thermoregulation in patients after cardiac arrest: a retrospective cohort study.

PURPOSE: Core body temperature has been extensively investigated as a thereuptic target in care after cardiac arrest. Nevertheless, the integrity of thermoregulation in patients after cardiac arrest has not been well studied. We sought to evaluate whether low spontaneous body temperature after cardiac arrest is associated with increased death and a worse neurologic outcome, and whether patients with low spontaneous body temperature exhibit features suggestive of impaired thermoregulation. METHODS: We conducted a single-centre retrospective cohort study. We included all adult patients who underwent temperature control with hypothermia after cardiac arrest between 1 January 2014 and 30 June 2020. The primary exposure was low spontaneous core body temperature (< 35 °C) at initiation of hypothermia therapy. The primary outcome was in-hospital death and the secondary outcome was poor neurologic outcomes at discharge. RESULTS: Five hundred and ninety-seven adult patients, comprising both in- and out-of-hospital cardiac arrests, were included. Patients with low spontaneous body temperature also had slightly lower average temperature, and more frequent transient but controlled breakthrough fever episodes in the first 24 hr. In the multivariable logistic regression analysis, low spontaneous body temperature was associated with higher odds of in-hospital death (odds ratio, 2.9; 95% confidence interval, 1.9 to 4.2; P < 0.001). CONCLUSION: In this single-centre retrospective cohort study, low spontaneous core body temperature was associated with poor outcomes in patients after cardiac arrest. Patients with low spontaneous body temperature also exhibited features suggestive of impaired thermoregulation. Further research is needed to determine whether body temperature upon presentation reflects the robustness of the patient's underlying physiology and severity of brain insult after a cardiac arrest.

RéSUMé: OBJECTIF: La température corporelle centrale a fait l'objet d'études approfondies en tant que cible thérapeutique dans les soins après un arrêt cardiaque. Néanmoins, l'intégrité de la thermorégulation après un arrêt cardiaque n'a pas été bien étudiée. Nous avons cherché à évaluer si une température corporelle spontanément basse après un arrêt cardiaque était associée à une augmentation de la mortalité et à une issue neurologique plus grave, et si les individus ayant une température corporelle spontanément basse présentaient des caractéristiques suggérant une altération de la thermorégulation. MéTHODE: Nous avons mené une étude de cohorte rétrospective monocentrique. Nous avons inclus tou·tes les patient·es adultes ayant bénéficié d'un contrôle de température lors d'une hypothermie après un arrêt cardiaque entre le 1er janvier 2014 et le 30 juin 2020. L'exposition principale était une température corporelle centrale spontanément basse (< 35 °C) au début du traitement de l'hypothermie. Le critère d'évaluation principal était le décès à l'hôpital, et le critère d'évaluation secondaire était de mauvaises issues neurologiques à la sortie de l'hôpital. RéSULTATS: Cinq cent quatre-vingt-dix-sept patient·es adultes, ayant subi des arrêts cardiaques à l'hôpital ou hors de l'hôpital, ont été inclus·es. Les patient·es ayant une température corporelle spontanément basse avaient également une température moyenne légèrement plus basse et des épisodes de fièvre paroxystique transitoires mais contrôlés plus fréquents au cours des premières 24 heures. Dans l'analyse de régression logistique multivariée, une température corporelle spontanément basse était associée à une probabilité plus élevée de décès à l'hôpital (rapport de cotes, 2,9; intervalle de confiance à 95 %, 1,9 à 4,2; P < 0,001). CONCLUSION: Dans cette étude de cohorte rétrospective monocentrique, une température corporelle centrale spontanément basse a été associée à de mauvais devenirs après un arrêt cardiaque. Les patient·es présentant une température corporelle spontanément basse présentaient également des caractéristiques suggérant une altération de la thermorégulation. D'autres recherches sont nécessaires pour déterminer si la température corporelle lors de la présentation reflète la robustesse de la physiologie sous-jacente des patient·es et la gravité de la lésion cérébrale après un arrêt cardiaque.

Robust Zero Modes in Non-Hermitian Systems without Global Symmetries.

We present an approach to achieve zero modes in lattice models that do not rely on any symmetry or topology of the bulk, which are robust against disorder in the bulk of any type and strength. Such symmetry-free zero modes (SFZMs) are formed by attaching a single site or small cluster with zero mode(s) to the bulk, which serves as the "nucleus" that expands to the entire lattice. We identify the requirements on the couplings between this boundary and the bulk, which reveals that this approach is intrinsically non-Hermitian. We then provide several examples with either an arbitrary or structured bulk, forming spectrally embedded zero modes in the bulk continuum, midgap zero modes, and even restoring the "zeroness" of coupling or disorder-shifted topological corner states. Focusing on viable realizations using photonic lattices, we show that the resulting SFZM can be observed as the single lasing mode when optical gain is applied to the boundary.

Introducing medical students to deep learning through image labelling: a new approach to meet calls for greater artificial intelligence fluency among medical trainees.

Our approach addresses the urgent need for AI experience for the doctors of tomorrow. Through a medical education-focused approach to data labelling, we have fostered medical student competence in medical imaging and AI. We envision our framework being applied at other institutions and academic groups to develop robust labelling programs for research endeavours. Application of our approach to core visual modalities within medicine (e.g. interpretation of ECGs, diagnostic imaging, dermatologic findings) can lead to valuable student experience and competence in domains that feature prominently in clinical practice, while generating much needed data in fields that are ripe for AI integration.

Notre approche répond au besoin urgent de familiariser les médecins de demain avec l'IA. Nous avons cherché à développer leurs compétences en imagerie médicale et en IA par une approche à l'étiquetage de données axée sur la formation médicale. D'autres établissements et groupes universitaires souhaitant mettre sur pied des programmes d'étiquetage solides pour leurs projets de recherche pourraient adopter notre modèle. L'application de notre approche aux principales modalités visuelles en médecine (par exemple, l'interprétation des ECG, l'imagerie diagnostique, le diagnostic des lésions dermatologiques) peut permettre aux étudiants d'acquérir une expérience et des compétences précieuses dans des domaines importants de la pratique clinique, tout en procurant des données indispensables dans des secteurs qui sont mûrs pour une intégration de l'IA.

The impact of music, play, and pet therapies in managing pain and anxiety in paediatric patients in hospital: a rapid systematic review.

Background: Hospitalized children face pain and anxiety associated with the environment and procedures. Objective: This review aimed to assess the impact of music, play, pet and art therapies on pain and anxiety in hospitalized paediatric patients. RCTs assessing the impact of music, play, pet, and/or art therapies on pain and/or anxiety in hospitalized paediatric patients were eligible. Methods: Database searching and citation screening was completed to identify studies. A narrative synthesis was used to summarize study findings and certainty of evidence was assessed using GRADE. Of the 761 documents identified, 29 were included spanning music (n = 15), play (n = 12), and pet (n = 3) therapies. Results: A high certainty of evidence supported play in reducing pain and moderate certainty for music and pet. A moderate certainty of evidence supported music and play in reducing anxiety. Conclusion: Complementary therapies utilized alongside conventional medical treatment may mitigate pain and anxiety in hospitalized paediatric patients.

Plasma-first resuscitation to treat haemorrhagic shock during emergency ground transportation in an urban area: a randomised trial.

BACKGROUND: Plasma is integral to haemostatic resuscitation after injury, but the timing of administration remains controversial. Anticipating approval of lyophilised plasma by the US Food and Drug Administration, the US Department of Defense funded trials of prehospital plasma resuscitation. We investigated use of prehospital plasma during rapid ground rescue of patients with haemorrhagic shock before arrival at an urban level 1 trauma centre. METHODS: The Control of Major Bleeding After Trauma Trial was a pragmatic, randomised, single-centre trial done at the Denver Health Medical Center (DHMC), which houses the paramedic division for Denver city. Consecutive trauma patients in haemorrhagic shock (defined as systolic blood pressure [SBP] ≤70 mm Hg or 71-90 mm Hg plus heart rate ≥108 beats per min) were assessed for eligibility at the scene of the injury by trained paramedics. Eligible patients were randomly assigned to receive plasma or normal saline (control). Randomisation was achieved by preloading all ambulances with sealed coolers at the start of each shift. Coolers were randomly assigned to groups 1:1 in blocks of 20 according to a schedule generated by the research coordinators. If the coolers contained two units of frozen plasma, they were defrosted in the ambulance and the infusion started. If the coolers contained a dummy load of frozen water, this indicated allocation to the control group and saline was infused. The primary endpoint was mortality within 28 days of injury. Analyses were done in the as-treated population and by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01838863. FINDINGS: From April 1, 2014, to March 31, 2017, paramedics randomly assigned 144 patients to study groups. The as-treated analysis included 125 eligible patients, 65 received plasma and 60 received saline. Median age was 33 years (IQR 25-47) and median New Injury Severity Score was 27 (10-38). 70 (56%) patients required blood transfusions within 6 h of injury. The groups were similar at baseline and had similar transport times (plasma group median 19 min [IQR 16-23] vs control 16 min [14-22]). The groups did not differ in mortality at 28 days (15% in the plasma group vs 10% in the control group, p=0·37). In the intention-to-treat analysis, we saw no significant differences between the groups in safety outcomes and adverse events. Due to the consistent lack of differences in the analyses, the study was stopped for futility after 144 of 150 planned enrolments. INTERPRETATION: During rapid ground rescue to an urban level 1 trauma centre, use of prehospital plasma was not associated with survival benefit. Blood products might be beneficial in settings with longer transport times, but the financial burden would not be justified in an urban environment with short distances to mature trauma centres. FUNDING: US Department of Defense.

Breastfeeding indicators among a nationally representative multi-ethnic sample of New Zealand children.

AIMS: To describe breastfeeding initiation and duration, and demographic associations with breastfeeding duration within a representative sample of New Zealand infants. METHODS: In 6,685 singletons enrolled in the Growing Up in New Zealand cohort we described breastfeeding initiation (96%), any (94%) and exclusive (93%) breastfeeding (EBF) duration. We used adjusted relative risk (RR) and 95% confidence intervals (CI) to describe associations with breastfeeding duration. RESULTS: Breastfeeding initiation occurred for 97%. Sixteen percent were EBF to age six months and 13% were breastfed to age 24 months. Exclusive breastfeeding for ≥4 months was less likely for children of mothers of Maori (RR=0.80, 95% CI 0.73-0.87), Pacific (0.90, 95% CI 0.83-0.98) or Asian (0.80, 95% CI 0.74-0.86) ethnicity. Children of mothers aged 20-29 years (1.24, 95% CI 1.04-1.49); ≥30 years (1.36, 95% CI 1.14-1); with a tertiary education (1.14, 95% CI 1.08-1.21); or planned pregnancy (1.14, 95% CI 1.08-1.21); and children with older siblings (RR=1.31, 95% CI 1.17-1.47) were more likely to be exclusively breastfed for ≥4 months. Children were more likely to be breastfed ≥6 months if their mother was aged 20-29 (1.26, 95% CI 1.10-1.45) or ≥30 years (1.40, 95% CI 1.22-1.61), had a tertiary education (1.11, 95% CI 1.06-1.59) or planned pregnancy (1.11, 95% CI 1.06-1.15), or if they had older siblings (1.04, 95% CI 1.00-1.08). CONCLUSION: In New Zealand, most children are initially breastfed, however a large proportion did not receive the recommended duration of any or exclusive breastfeeding. Maternal age, education, parity and pregnancy planning identify children at risk of shorter duration of breastfeeding and EBF, and maternal ethnicity identifies children at risk of shorter EBF duration.

The "Death Diamond": Rapid thrombelastography identifies lethal hyperfibrinolysis.

BACKGROUND: Postinjury hyperfibrinolysis (HF), defined as LY30 of 3% or greater on rapid thrombelastography (rTEG), is associated with high mortality and large use of blood products. We observed that some cases of HF are reversible and are associated with patients who respond to hemostatic resuscitation; however, other cases of severe HF seem to be associated with these patients' inevitable demise. We therefore sought to define this unsurvivable subtype of HF as a recognizable rTEG tracing pattern. METHODS: We queried our trauma registry for patients who either died or spent at least 1 day in the intensive care unit, received at least 1 U of packed red blood cells, and had an admission rTEG. Within this group of 572 patients, we identified 42 pairs of nonsurvivors and survivors who matched on age, sex, injury mechanism, and New Injury Severity Score (NISS). We inspected the rTEG tracings to ascertain if any pattern was found exclusively within the nonsurviving group and applied these findings to the cohort of 572 patients to assess the predictive value for mortality. RESULTS: Within the matched group, 17% of the patients developed HF. Within the HF subgroup, a unique rTEG pattern was present in 14 HF patients who died and in none of the survivors. This pattern was a "diamond-shaped" tracing with a short time to maximum amplitude of 14 minutes or shorter and complete lysis before the LY30 point. When these criteria are applied to the 572 unmatched patients, this pattern had a 100% positive predictive value for mortality. CONCLUSION: Patients displaying the "death diamond" pattern on their admission rTEG are at higher risk for mortality. Given the volume of blood products and other resources that these patients consume, this thrombelastography pattern may represent an objective criterion to discontinue efforts at hemostatic resuscitation. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.

How do you recruit and retain a prebirth cohort? Lessons learnt from growing up in New Zealand.

Growing Up in New Zealand, a longitudinal study following nearly 7,000 children, has faced some unique challenges in identifying, enrolling, and retaining a large and diverse antenatal cohort. Identification of a study region with population demographics that enabled enrollment of an appropriately diverse sample was required as was intensive community and participant engagement in order to promote the study. Complementary methods used included direct engagement with prospective participants and the community and indirect engagement via media. Thus far, retention rates above 95% have been achieved by maintaining a multimethod approach that includes valuing participants and building trusting relationships, strong brand recognition, community engagement, maintenance of participant contact and location records, ensuring high-quality interactions between the participants and the study, pretesting measures and methods prior to the main cohort, and using participant feedback to inform the measures and methods used in future waves of data collection.

An evaluation of the use of eye gaze to measure preference of individuals with severe physical and developmental disabilities.

OBJECTIVE: The purpose of this study was to examine whether duration of eye gaze could be used to identify reinforcing stimuli for four individuals with severe physical and developmental disabilities, as well as the effectiveness of the assessment using different numbers of stimuli (i.e. 6 vs 14). METHODS: This study measured each student's preferences in a paired stimulus preference assessment using duration of eye gaze toward various stimuli. Following the preference assessment, a reinforcer assessment was conducted within a reversal design to determine the accuracy of the preference hierarchy. RESULTS: Results indicated that duration of eye gaze toward a stimulus was successful in identifying preferred stimuli that functioned as reinforcers for all participants. Additionally, the shorter preference assessment produced measures of similar accuracy in considerably less time. CONCLUSION: Eye gaze can be used to identify reinforcing stimuli for individuals with severe physical and developmental disabilities.