Acute Life-threatening Events Research Articles

Cost-effectiveness of behavioural counselling intervention compared with non-intervention for adult patients with metabolic syndrome to prevent cardiovascular diseases and type 2 diabetes in Japan: a microsimulation modelling study

ObjectivesNationwide lifestyle intervention—specific health guidance (SHG) in Japan—employs counselling and education to change unhealthy behaviours that contribute to metabolic syndrome, especially obesity or abdominal obesity. We aimed to perform a...

Electrifying insights into cardiac arrhythmias: from molecular mechanisms to therapeutic translations

Disruptions to normal bioelectric rate and rhythm profiles in the heart are cardiac arrhythmias. Their impacts range from minor discomforting symptoms to acute or chronic life-threatening events, with atrial fibrillation increasing the risk of stroke and heart failure, and ventricular arrhythmia associated with sudden cardiac death. To improve mechanistic understandings and advance potential approaches to treatment of arrhythmias, this Interface Focus themed issue on cardiac electrophysiology is a collection of recent studies. They investigate some of the molecular and cellular mechanisms or tissue substrates instigating and maintaining arrhythmia, and discover relevant imaging and signalling biomarkers that assess arrhythmic risks. The studies use imaging, computer simulations, machine learning and both human and animal models in their investigations exploring basic science and strategies for early recognition and improved treatment strategies.

Emergencies in Oncological Practice

Oncological emergencies are defined as an acute lifethreatening event in a patient with a tumor occurring as part of their complex treatment regimen or secondarily to their underlying malignancy. These events can occur at any time from the initial diagnosis of their cancer to endstage disease; and can be encountered in any clinical setting, ranging from primary care physician and emergency department visits to a variety of subspecialty environments. Oncologic emergencies are clinical situations that can lead to death in a short time (24-48 hours) if not quickly faced. In the clinical practice of the medical oncologist, such situations do not infrequently occur. The onset of oncologic emergencies may depend on the presence of cancer itself, the therapies carried out to counteract cancer, or the patient’s predisposition to develop such events. It is essential to recognize the aforementioned situations early in order to treat them promptly, thus avoiding serious consequences. BJM Vol. 34 No. 2(1) Suppliment 2023 Scientific Presentation 186 Therefore, it is critically important that all physicians have a working knowledge of the potential oncological emergencies that may present in their practice and how to provide the most effective care without delay. Nervous system emergencies include spinal cord compression, raised ICP, leptomeningeal disease, seizures and altered mental status whereas superior venacaval syndrome, hyperviscocity syndrome, hyperleukocytosis, venous thromboembolism, Hemorrhage and DIC are the vascular and haematologic emergencies. Several classic metabolic oncologic emergencies include syndrome of inappropriate antidiuretic hormone secretion, tumor lysis syndrome and hypercalcemia of malignancy. Among the pulmonary problems airway obstruction, massive haemoptysis, toxic lung injuries, pneumonitis and pulmonary fibrosis can be caused by cancer and cancer treatment. Urologic emergencies such as hemorrhagic cystitis and obstructive uropathy are also seen. Gastrointestinal bleeding in patients with cancer and typlitis in patients with neutropenic fever are potentially serius complications also. Immune check point inhibitors may cause irAEs in practically any organ system ranging from SJS, TEN, thyroiditis, hypophysitis, adrenilitis, diabetic ketoacidosis to life threatening pneumonitis and myocarditis which may be associated with poor overall survival. Oncologic emergencies can threaten the well-being of almost any patient with a malignancy. Although some of these conditions are related to cancer therapy, they are by no means confined to the period of initial diagnosis and active treatment. In the setting of recurrent malignancy, these events can occur years after the surveillance of a cancer patient has been appropriately transferred from a medical oncologist to a primary care provider. As such, awareness of a patient’s cancer history and its possible complications forms an important part of any clinician’s knowledge base. Prompt identification of and intervention in these emergencies can prolong survival and improve quality of life, even in the setting of terminal illness. Bangladesh J Medicine 2023; Vol. 34, No. 2(1) Supplement: 186-187

Surgical management of acute life-threatening events affecting esophageal atresia and/or tracheoesophageal fistula patients

BackgroundFollowing surgical correction, many patients with esophageal atresia with or without tracheoesophageal fistula (EA/TEF) present to the emergency department (ED) with acute airway complications. We sought to determine the incidence and risk factors for severe acute life-threatening events (ALTEs) in pediatric patients with repaired congenital EA/TEF and the outcomes of operative interventions. MethodsA retrospective cohort chart review was performed on patients with EA/TEF with surgical repair and follow-up at a single centre from 2000 to 2018. Primary outcomes included 5-year ED visits and/or hospitalizations for ALTEs. Demographic, operative, and outcome data were collected. Chi-square tests and univariate analyses were performed. ResultsIn total, 266 EA/TEF patients met inclusion criteria. Of these, 59 (22.2%) had experienced ALTEs. Patients with low birth weight, low gestational age, documented tracheomalacia, and clinically significant esophageal strictures were more likely to experience ALTEs (p < 0.05). ALTEs occurred prior to 1 year of age in 76.3% (45/59) of patients with a median age at presentation of 8 months (range 0–51 months). Recurrence of ALTEs after esophageal dilatation was 45.5% (10/22), mostly due to stricture recurrence. Patients experiencing ALTEs received anti-reflux procedures (8/59, 13.6%), airway pexy procedures (7/59, 11.9%), or both (5/59, 8.5%) within a median age of 6 months of life. The resolution and recurrence of ALTEs after operative interventions are described. ConclusionSignificant respiratory morbidity is common among patients with EA/TEF. Understanding the multifactorial etiology and operative management of ALTEs have an important role in their resolution. Type of StudyOriginal Research, Clinical Research. Level of EvidenceLevel III Retrospective Comparative Study.

Anaphylaxis: Long-term management and resources.

Background: Anaphylaxis is an acute life-threatening event that requires emergent diagnosis and treatment. However, focus on prevention of anaphylaxis is essential in reducing anaphylaxis recurrences and associated mortality. Objective: This literature review was aimed to be a comprehensive resource for practicing allergists in managing anaphylaxis in the long term. We discussed the role of the allergist in the long-term outpatient management of anaphylaxis through identifying risk factors, allergen avoidance, prevention of recurrences, and patient education. Methods: A medical literature search that focused on several areas of long-term management of anaphylaxis was conducted. Results: Patients evaluated by an allergist are more likely to have their anaphylaxis trigger identified, to have their underlying mast cell disorder diagnosed, and to receive desensitization or allergen immunotherapy. Allergists can prevent fatal anaphylaxis by preventing and treating anaphylaxis in patients with ischemic heart disease and by optimally treating patients with comorbid asthma. Allergists can offer specific prevention strategies for allergenic trigger and cofactor avoidance. Education should be focused on patients with a higher risk for recurrence of anaphylaxis, such as those patients with a history of severe symptoms or anaphylaxis, with a peanut and/or tree nut trigger, or with a history of asthma, or female gender. Patient counseling involves providing individualized action plans at each visit and discussing proper use, storage, and safety of epinephrine autoinjectors. Multiple doses of epinephrine need to be prescribed to those who are at risk for severe food-induced, venom immunotherapy-related, or venom-induced anaphylaxis. Wording on medical identification products should be reviewed by the allergist. Anaphylaxis resources for health-care providers are summarized in the article. Conclusion: Ongoing education, providing personalized anaphylaxis action plans, reducing risk factors, and avoiding triggers are key to anaphylaxis prevention and long-term management.

Depression and anxiety up to two years after acute pulmonary embolism: Prevalence and predictors

IntroductionPulmonary embolism (PE) is an acute life-threatening event. Besides known physical long-term consequences such as persistent dyspnoea or reduced physical performance, less attention is given to the emotional experience. MethodsWe used data from patients with PE of the ‘Lungenembolie Augsburg (LEA)’ cohort study at University Hospital Augsburg. Baseline characteristics were collected during hospital stay and participants received postal questionnaires 3, 6, 12, and 24 months after their PE event. Mental problems were assessed by the Hospital Anxiety and Depression Scale (HADS). Differences in baseline characteristics in patients with or without depression or anxiety at 3 months were tested. Linear mixed models were built to explore long-term effects. ResultsAbout one-in-five of the 297 patients suffered from depressive or anxiety symptoms after PE. Patients with depressiveness 3 months after PE were found to be significantly older, had a higher simplified pulmonary embolism severity index (sPESI), higher education level, more frequently previous depression, lower oxygen saturation, and a longer hospital stay. Linear mixed models revealed significant associations of age, history of depression and sPESI with HADS depression score, and symptoms of dyspnoea with HADS anxiety score after PE. While the association with sPESI decreased over time, persistent dyspnoea and limitations in daily life showed constant associations over the two-year time period for both, depression and anxiety. ConclusionsThe findings highlight depression and anxiety to be common in patients with PE and reveal possible predictors. Careful monitoring the mental health of patients with PE is needed for early detection and intervention.

Cerebrolysin Use in Patients with Liver Damage-A Translational Study.

The treatment of acute life-threatening events in patients suffering from chronic pathologies is problematic, as physicians need to consider multisystemic drug effects. Regarding Cerebrolysin, a Sonic Hedgehog signaling pathway amplifier and one of the few approved neurotrophic treatments for stroke patients, concerns of excessive Hedgehog pathway activation that could accelerate NAFLD progression to cirrhosis seem valid. We investigated stroke patients treated with Cerebrolysin that presented elevated levels of aspartate aminotransferase (AST) and/or alanine aminotransferase (ALT). We also investigated the efficiency of Cerebrolysin in reversing the neurogenesis inhibition within the hippocampus in a mouse model of NAFLD by evaluating behavior and histological outcomes. NeuN, BrdU and Iba1 positive signals in the cortex and hippocampus of the animals were also observed. Clinically, Cerebrolysin improved AST levels in a majority of stroke patients with hepatic damage. The same treatment in an experimental setup was able to reverse anxiety-like behavior in MCD mice, reducing their freezing time from 333.61 ± 21.81 s in MCD animals to 229.17 ± 26.28 in treated ones. The use of Cerebrolysin did not improve short-term memory nor rescued cell multiplication in the hippocampus after MCD food intake. Understanding the neuroprotective and neurotrophic effects that drugs have on NAFLD patients can significantly contribute to a suitable therapeutic approach.

Resting-state functional connectome predicts individual differences in depression during COVID-19 pandemic.

Stressful life events are significant risk factors for depression, and increases in depressive symptoms have been observed during the COVID-19 pandemic. The aim of this study is to explore the neural makers for individuals' depression during COVID-19, using connectome-based predictive modeling (CPM). Then we tested whether these neural markers could be used to identify groups at high/low risk for depression with a longitudinal dataset. The results suggested that the high-risk group demonstrated a higher level and increment of depression during the pandemic, as compared to the low-risk group. Furthermore, a support vector machine (SVM) algorithm was used to discriminate major depression disorder patients and healthy controls, using neural features defined by CPM. The results confirmed the CPM's ability for capturing the depression-related patterns with individuals' resting-state functional connectivity signature. The exploration for the anatomy of these functional connectivity features emphasized the role of an emotion-regulation circuit and an interoception circuit in the neuropathology of depression. In summary, the present study augments current understanding of potential pathological mechanisms underlying depression during an acute and unpredictable life-threatening event and suggests that resting-state functional connectivity may provide potential effective neural markers for identifying susceptible populations. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Effect of sleep position in term healthy newborns on sudden infant death syndrome and other infant outcomes: A systematic review.

BackgroundThough recommended by numerous guidelines, adherence to supine sleep position during the first year of life is variable across the globe.MethodsThis systematic review of randomized trials and observational studies assessed the effect of the supine compared to non-supine (prone or side) sleep position on healthy newborns. Key outcomes were neonatal mortality, sudden infant death syndrome (SIDS), sudden unexpected death in infancy (SUDI), acute life-threatening event (ALTE), neurodevelopment, and positional plagiocephaly. We searched MEDLINE via PubMed, Cochrane CENTRAL, EMBASE, and CINAHL (updated till November 2021). Two authors separately evaluated the risk of bias, extracted data, and synthesised effect estimates using relative risk (RR) or odds ratio (OR). The GRADE approach was used to assess the certainty of evidence.ResultsWe included 54 studies (43 observational studies and 11 intervention trials) involving 474 672 participants. A single study meeting the inclusion criteria suggested that the supine sleep position might reduce the risk of SUDI (0-1 year; OR = 0.39, 95% confidence interval (CI) = 0.23-0.65; 384 infants), compared to non-supine position. Supine sleep position might reduce the risk of SIDS (0-1 year; OR = 0.51, 95% CI = 0.42-0.61; 26 studies, 59332 infants) and unexplained SIDS/severe ALTE (neonatal period; OR = 0.16, 95% CI = 0.03-0.82; 1 study, 119 newborns), but the evidence was very uncertain. Supine sleep position probably increased the odds of being 0.5 standard deviation (SD) below mean on Gross Motor Scale at 6 months (OR = 1.67, 95% CI = 1.22-2.27; 1 study, 2097 participants), but might have little to no effect at 18 months of age (OR = 1.16, 95% CI = 0.96, 1.43; 1 study, 1919 participants). An increase in positional plagiocephaly at 2-7 months of age with supine sleep position is possible (OR = 2.77, 95% CI = 2.06-3.72; 6 studies, 1774 participants).ConclusionsLow- to very low-certainty evidence suggests that supine sleep position may reduce the risk of SUDI (0-1 year) and SIDS (0-1 year). Limited evidence suggests that supine sleeping probably delays short-term ‘gross motor’ development at 6 months, but the effect on long-term neurodevelopment at 18 months may be negligible.

Emergencies in Oncology

Oncological emergencies are defined as any acute possible morbid or life-threatening events in patients with cancer either because of the malignancy or because of their treatment. With advances in antitumor therapy, the prognosis of oncological diseases has improved, so the management of their complications, whether due to the tumors themselves or their respective treatments, becomes more important day by day. These events may occur at any time during malignancy, from symptoms present to end-stage disease. Metabolic syndromes include Tumor Lysis Syndrome and Hypercalcemia. Compression Syndromes includes Superior Vena Cava Syndrome and Spinal Cord Compression Syndrome.

Emergencies in Oncology

Oncological emergencies are defined as any acute possible morbid or life-threatening events in patients with cancer either because of the malignancy or because of their treatment. With advances in antitumor therapy, the prognosis of oncological diseases has improved, so the management of their complications, whether due to the tumors themselves or their respective treatments, becomes more important day by day. These events may occur at any time during malignancy, from symptoms present to end-stage disease. Metabolic syndromes include Tumor Lysis Syndrome and Hypercalcemia. Compression Syndromes includes Superior Vena Cava Syndrome and Spinal Cord Compression Syndrome.

Paediatric tracheobronchomalacia: Incidence, patient characteristics, and predictors of surgical intervention

ObjectivesTracheobronchomalacia (TBM), a condition where an abnormality of the tracheal walls causes collapse during the respiratory cycle, is a common cause of airway obstruction in childhood. TBM can present with a large spectrum of disease severity and underlying pathologies that may be managed medically and surgically, and it is not always clear which patients would most benefit from surgical intervention. We aim to describe the incidence, patient characteristics, and predictors of surgical intervention in a large cohort of paediatric patients. MethodsWe performed a retrospective review of all children diagnosed with TBM to a paediatric Otolaryngology unit in the west of Scotland between 2010 and 2020. Odds ratios for clinical predictors of surgery were calculated using logistic regression with uni- and multivariate analysis. Results249 patients were identified of which 219 proceeded to data collection. Primary malacia was noted in 161 (73.5%) and secondary in 58 (26.5%). Causes of secondary malacia included compression by the innominate artery (11%) and vascular rings (7.8%). Surgical interventions were performed in 28 patients (12.8%) including division of vascular ring, aortopexy, and surgical tracheostomy. Multivariate analysis showed secondary TBM, acute life-threatening events, and difficulty weaning from mechanical ventilation were independent risk factors for surgical intervention. ConclusionsTBM can present with a myriad of airway symptoms and is frequently associated with other airway and mediastinal pathologies necessitating multiple interventions. Children aged <1 year present with a more severe form of the disease and the presence of particular independent risk factors may indicate a need for surgical intervention. Level of evidence4

Emergencies in Oncology

Oncological emergencies are defined as any acute possible morbid or life-threatening events in patients with cancer either because of the malignancy or because of their treatment. With advances in antitumor therapy, the prognosis of oncological diseases has improved, so the management of their complications, whether due to the tumors themselves or their respective treatments, becomes more important day by day. These events may occur at any time during malignancy, from symptoms present to end-stage disease. Metabolic syndromes include Tumor Lysis Syndrome and Hypercalcemia. Compression Syndromes includes Superior Vena Cava Syndrome and Spinal Cord Compression Syndrome.

Post-operative bronchoscopy findings of esophageal atresia patients, initial phase of single-institute experience

BackgroundEsophageal atresia (EA) is not a rare congenital anomaly. It is usually accompanied by tracheoesophageal fistula (TEF). Respiratory morbidities are experienced in most of the survivors. Although it was believed that these symptoms tend to improve by age, permanent lung damage may continue to adulthood in some patients. We aimed to assess the respiratory tract in the follow-up period as an attempt to correlate possible findings with symptoms experienced which allowed us to pay more attention to the respiratory tract during the upcoming surgical interventions. Prospective observational study was conducted on patients presented to our institute, throughout 2018, with various degrees of refractory respiratory tract involvement, after having had their EA repaired inside or outside our institute. After exclusion of esophageal causes of these manifestations, bronchoscopy was performed to correlate the findings with the symptoms experienced by these patients. The study does not include patients repaired after 2018 as surgical modifications were performed and are still under study.ResultsFifteen patients presented with various respiratory symptoms. Although recurrent chest infection is the commonest presentation, acute life-threatening events were reported in 5 patients. Blind-ended tracheal diverticulum was the most common finding observed in 80% of patients. About 76% of these patients were found to have tracheomalacia. Moreover, bronchoscopy was able to detect recurrent tracheoesophageal fistula in 4 patients. Vocal cords were affected in 13% of these patients.ConclusionsFrequent respiratory symptoms in operated patients warrant careful long-term monitoring and appropriate management. Although bronchoscopy is considered a mandatory pre-repair procedure, it is a crucial tool in evaluating the survivors. It is pivotal to pay more attention to the respiratory tract to modify the surgical techniques to overcome these pitfalls.

An updated narrative review on the management of the most common oncological and hematological emergencies

Oncological emergencies are defined as an acute life-threatening event in a patient with a tumor occurring as part of their complex treatment regimen or secondarily to their underlying malignancy. These events can occur at any time from the initial diagnosis of their cancer to end-stage disease. These oncological emergencies are broadly classified into four major categories; metabolic, structural, hematological and treatment-related causes; and can be encountered in any clinical setting, ranging from primary care physician and emergency department visits to a variety of subspecialty environments.This study aims to cover an in-depth review of the underlying pathogenesis, clinical presentation, and updated management protocol of most common emergencies belonging to the above-mentioned categories. An all-language literature search was conducted on 15th October 2021 and 10th March 2022, limited to 5 years on PubMed database using the following search strings: oncological emergencies, malignant spinal cord compression, febrile neutropenia, hyperviscosity syndrome, superior vena cava syndrome, immune related adverse events, tumor lysis syndrome, hypercalcemia of malignancy, corrected calcium, malignant pericardial effusion and chemotherapy extravasation.

Real-World Experience of Patients with Sickle Cell Disease Treated with Voxelotor: A Multicenter, Retrospective Study

Real-World Experience of Patients with Sickle Cell Disease Treated with Voxelotor: A Multicenter, Retrospective Study

Chronic subdural hemorrhage predisposes to development of cerebral venous thrombosis and associated retinal hemorrhages and subdural rebleeds in infants.

For infants presenting with subdural hemorrhage, retinal hemorrhage, and neurological decline the "consensus" opinion is that this constellation represents child abuse and that cerebral venous sinus thrombosis and cortical vein thrombosis is a false mimic. This article contends that this conclusion is false for a subset of infants with no evidence of spinal, external head, or body injury and is the result of a poor radiologic evidence base and misinterpreted data. Underdiagnosis of thrombosis is the result of rapid clot dissolution and radiologic under recognition. A pre-existing/chronic subdural hemorrhage predisposes to development of venous sinus thrombosis/cortical vein thrombosis, triggered by minor trauma or an acute life-threatening event such as dysphagic choking, variably leading to retinal and subdural hemorrhages and neurologic decline. These conclusions are based on analysis of the neuroradiologic imaging findings in 11 infants, all featuring undiagnosed cortical vein or venous sinus thrombosis. Subtle neuroradiologic signs of and the mechanisms of thrombosis are discussed. Subarachnoid hemorrhage from leaking thrombosed cortical veins may be confused with acute subdural hemorrhage and probably contributes to the development of retinal hemorrhage ala Terson's syndrome. Chronic subdural hemorrhage rebleeding from minor trauma likely occurs more readily than bleeding from traumatic bridging vein rupture. Radiologists must meet the challenge of stringent evaluation of neuro imaging studies; any infant with a pre-existing subdural hemorrhage presenting with neurologic decline must be assumed to have venous sinus or cortical vein thrombosis until proven otherwise.

Exertional Heat Stroke Causes Long‐Term Satellite Cell Dysfunction and Delayed Muscle Repair

Exertional heat stroke (EHS) is an acute life-threatening event that appears to lead to long-term health problems such as cardiovascular disease and immunosuppression. However, how skeletal muscle (SKM) is affected in the long term by EHS is not well understood. One well-known acute effect of EHS on SKM is rhabdomyolysis (RM), caused by SKM damage. To regain muscle function, this damage requires an effective muscle repair response, which is likely to include a robust contribution of progenitor satellite cell (SCs). We hypothesized that SCs display EHS-induced phenotype changes that contribute to a delay in the muscle repair process. Purpose To determine whether EHS exposure alters SC phenotype after 30 d of recovery in mice and to evaluate whether this impairs muscle repair. Methods Thirty-two female mice were either subjected to a standardized EHS protocol using a forced running wheel (environmental temp: 37.5°C, 40% humidity) or a matched exercise control trial (EXC)(22.5°C). The EHS mice achieved peak core temps of ~42.2°C accompanied by transient loss of consciousness. Mice were sacrificed at 30 d of recovery. In one cohort (N=8/group), SKM was collected to isolate SCs for quantification of proliferation patterns every 24 h over 96 h and to determine their myogenic ability. Of the eight EHS SC isolations, three were unable to proliferate at all following isolation, a response not seen in any control SC populations. Since a significant portion of the samples did not respond, we used a nominal stratification classification for statistical analysis. In a second cohort, SKM was collected to sequence mRNA and perform Western protein analyses. Results EHS SCs were found to proliferate significantly less than EXC SCs at the 72 h & 96 h time points (P=0.0273); however, the ability to differentiate into myotubes was not different. mRNA analysis of EHS gastroc elucidated a robust, ongoing oxidative muscle transcriptional process at 30 d that included upregulation of such genes as Myh6, Myh7, Atp2a2, Casq2, Tnnc1, Tnnt1, and Tnni1. This response was not seen in isoforms associated with fast glycolytic muscle genes. The mRNA encoding embryonic myosin, Myh3, was found upregulated, an indicator of muscle regeneration. The protein encoded by adult oxidative myosin (Myh7) was found to be significantly less in EHS muscle (P<0.01), whereas Myh4 protein was not different and Myh3 was undetectable in either group. Conclusions SC proliferation following 30 d of recovery from a single incidence of EHS is significantly attenuated in female mice. This phenomenon has the potential to hinder the renewal of the SC pool, following depletion, and leading to delayed muscle repair. This delay may be apparent in EHS muscle through significantly lower Myh7 protein in EHS muscle and an ongoing oxidative gene transcription program.

Non-traumatic pediatric intracranial hypertension: key points for different etiologies, diagnosis, and treatment.

Intracranial hypertension can be an acute life-threatening event or slowly deteriorating condition, leading to a gradual loss of neurological function. The diagnosis should be taken in a timely fashioned process, which mandates expedite measures to save brain function and sometimes life. An optimal management strategy is selected according to the causative etiology with a core treatment paradigm that can be utilized in various etiologies. Distinct etiologies are intracranial bleeds caused by traumatic brain injury, spontaneous intracranial hemorrhage (e.g., neonatal intraventricular hemorrhage), or the rare pediatric hemorrhagic stroke. The other primary pediatric etiologies for elevated intracranial pressure are intracranial mass (e.g., brain tumor) and hydrocephalus related. Other unique etiologies in the pediatric population are related to congenital diseases, infectious diseases, metabolic or endocrine crisis, and idiopathic intracranial pressure. One of the main goals of treatment is to alleviate the growing pressure and prevent the secondary injury to brain parenchyma due to inadequate blood perfusion and eventually inadequate parenchymal oxygenation and metabolic state. Previous literature discussed essential characteristics of the treatment paradigm derived mainly from pediatric brain traumatic injuries' treatment methodology. Yet, many of these etiologies are not related to trauma; thus, the general treatment methodology must be tailored carefully for each patient. This review focuses on the different possible non-traumatic etiologies that can lead to intracranial hypertension with the relevant modification of each etiology's treatment paradigm based on the current literature.

Iatrogenic Pleural Effusion Due to Extravasation of Parenteral Nutrition via an Epicutaneo Cava Catheter in Neonates: A Prospective Cohort Study.

Background: Although Epicutaneo cava catheters (ECCs) are being routinely used for intravenous access for long-term parenteral nutrition and prolonged medication administration in neonates, ECC use can be associated with rare but acute life-threatening events such as pleural effusion (PE). It is important to identify and maintain the ECC tip in a central location for preventing complications. Recently, intracavitary electrocardiogram (IC-ECG) has been developed for the real-time monitoring and verification of ECC tip position.Objective: To investigate the causes and preventive measures of ECC-related PE in neonates.Methods: This prospective cohort study was conducted between January 2013 and December 2017. We observed and analyzed the clinical characteristics and causes of ECC-related PE. From January to December 2017, all ECCs were guided by IC-ECG. The incidence of ECC-related PE and first-attempt success rates were analyzed before and after the introduction of IC-ECG. Additionally, the sensitivity and specificity of IC-ECG were evaluated.Results: ECC-related PE was identified in 14 infants. Catheters were malpositioned in three cases; in the other 11 cases, catheters were located centrally on insertion but had migrated to non-central locations at the time of PE. After the introduction of IC-ECG, the incidence of PE was zero (P < 0.05). The incidence of ECC-related PE was lower when veins of the lower extremities were selected as the insertion site (P < 0.05). The first-attempt success rate was significantly higher in the group with IC-ECG-guided ECC placement than in the group without (P < 0.05). The sensitivity and specificity of IC-ECG were 97.9 and 84.6%, respectively.Conclusion: ECC-related PE can be associated with either primary malposition or migration of the catheter tip. IC-ECG can help detect malposition and migration of catheter tips and improve the first-attempt success rate. Choosing a lower extremity insertion site may help decrease the rate of ECC-related PE. In neonates, IC-ECG is a reliable positioning method for ECCs with superior sensitivity and specificity.