Acute Setting Research Articles

Arthroscopic assisted foveal repair of triangular fibrocartilage complex injuries associated with distal radioulnar joint instability

Introduction Foveal tears of tfcc are common causes of ulnar sided wrist pain. They are usually associted with druj instability. Reattachment using either arthroscopic or open techniques is considered the best treatment in acute settings. This is a retrospective study to evaluate clinical and functional results of arthroscopic assisted technique. Patients and methods 20 patients were enrolled in the study. 13 males and 7 females. Mean age was 26 years. Technique involved arthroscopic reattachment of the tfcc to its foveal foot print using direct foveal portal as described by Atzei et al. Results The mean follow-up period was 14 months ranging from 8 to 20 months No pain was recorded in 13 patients, mild pain in 4 patients, and moderate pain in 3 patients. The mean VAS score was 3.2. The mean Mayo score was 70%. Conclusion Arthroscopic assisted technique using direct foveal portal is a valuable technique with good reproducible results.

Poster 244: Magnetic Resonance Imaging versus Diagnostic Arthroscopy to Identify Intraarticular Pathology Associated with Patellar Instability: A High Rate of Discordant Findings Altering Surgical Treatment

Objectives: While uncommon, acute traumatic patellar dislocations can lead to recurrent symptoms of patellar instability in 15% to 45% of patients. Patellar stability is an interplay of bony and soft tissue restraints as well as anatomic factors, however, a mainstay of treatment remains reconstruction of the medial patellofemoral ligament (MPFL). Instability events can lead to intra-articular derangements of the knee, both in the acute and chronic patellar instability setting. These findings may not always be appropriately identified on magnetic resonance imaging (MRI). The incidence of these “surprise” injuries have not been previously reported. The purpose of this study is to determine the rates of coexisting intra-articular pathology in patients with patellar instability requiring MPFL reconstruction and elucidate any discordance between preoperative MRI findings and diagnostic arthroscopy findings. Methods: All patients undergoing MPFL reconstruction at a single institution between 2010 and 2023 were identified and preoperative MRI reports, defined as the most recent MRI report to the date of surgery with no interval traumatic events, were queried. Records without full MRI reports as read by a radiologist or cases in which a diagnostic arthroscopy was not conducted were excluded. MRI findings were discordant from arthroscopic findings if a lesion identified on diagnostic arthroscopy was not present in the full MRI report. Procedures that were undertaken because of these missed pathologies on MRI were recorded. Results: A total of 640 patients were identified during the study period, and 507 complete records were ultimately included. Preoperative MRI identified patellar osteochondral lesions or cartilage fissures in 333 patients (66%), loose bodies in 119 patients (24%), lateral femoral condyle osteochondral lesions or fissures in 97 patients (19%) and meniscus tears in 47 patients (9%). Among these patients, 172 (34%) had a diagnosis at the time of arthroscopy which was not identified on the preoperative MRI. These arthroscopic findings resulted in 75 loose body removals, 74 patellar shaving chondroplasties, 16 partial meniscectomies, 3 microfractures, 3 osteochondral lesion open reduction internal fixation, and 2 meniscal repairs which would have been missed without diagnostic arthroscopy due to discordant MRI findings. Conclusions: Over one-third of patients at a single institution who underwent diagnostic arthroscopy in the setting of patellar instability surgery had pathology identified which required surgical intervention that was not reported on a preoperative MRI. A comparison of MRI and diagnostic arthroscopy has been extensively reported on for other knee pathologies including ACL tear and lateral meniscal tear; however, there has been no similar investigation of the reliability of MRI for identification of concomitant pathology in the setting of patellar instability to date. The findings of this study highlight the importance of diagnostic arthroscopy in the treatment of patellar instability, the frequency with which this altered treatment, and the high preponderance of discordant MRI findings.

Hypnosis in Burn Care: Efficacy, Applications, and Implications for Austere Settings

Burn injuries are among the most traumatic events a person can endure, often causing significant psychological dysfunction and severe pain. Hypnosis shows promise as a complementary intervention to manage pain and reduce the psychological distress associated with burn injury and treatment. This paper reviews the literature regarding hypnosis and potential applications of hypnosis in the management of burns. Hypnosis offers an effective, low-cost intervention that is widely applicable in the management of burns and can play a role in more acute and austere settings where resources are often limited.

Comment on Levitt et al. Approach to Decompensated Right Heart Failure in the Acute Setting. J. Clin. Med. 2024, 13, 869.

We read with great interest the article titled "Approach to Decompensated Right Heart Failure in the Acute Setting" [...].

Reply to Brea et al. Comment on "Levitt et al. Approach to Decompensated Right Heart Failure in the Acute Setting. J. Clin. Med. 2024, 13, 869".

We would like to acknowledge and thank the authors of "Defining the Plethoric IVC" [...].

A survey of emergency medical service providers' perspectives regarding relatives influence on acute prehospital treatment of adult patients.

In the field of prehospital emergency medicine, specialized emergency medical service (EMS) providers interact with acutely ill patients and their relatives. The influence of family presence during in-hospital resuscitation is well described. However, no studies have previously assessed the influence of relatives' presence in the acute prehospital setting. The aim of this study was to investigate EMS providers' perspectives on relatives' impact on the acute prehospital treatment of adult patients. An online anonymous survey was distributed to all prehospital EMS providers in the Capital Region of Denmark. The survey included 25 research questions on a 5-point Likert scale, investigating relatives' influence on treatment in three different domains: positive, negative, and resuscitation. A higher domain score indicates a high level of agreement or frequency. Two hundred forty-six EMS providers completed the survey (84 ambulance technicians, 87 paramedics, and 75 physicians). There were no significant differences in the positive domain across professions (p = .175). Physicians had a statistically significant lower median score in the negative domain, compared with ambulance technicians and paramedics (2.50 vs. 2.63 and 2.63, p = .024). In the resuscitation domain, paramedics and physicians had a significant lower median score compared with ambulance technicians (3.00 and 3.00 vs. 3.14, p = .003). All professions were equally positive towards the relatives' presence and involvement in the acute prehospital setting. Physicians were less likely to be negatively influenced by the presence of relatives compared with ambulance technicians and paramedics. In all professions, increased experience led to improved comfort with handling relatives.

Early hypocoagulable state in traumatic brain injury patients: incidence, predisposing factors, and outcomes in a retrospective cohort study.

Coagulopathy development in traumatic brain injury (TBI) is among the significant complications that can negatively affect the clinical course and outcome of TBI patients. Timely identification of this complication is of utmost importance in the acute clinical setting. We reviewed TBI patients admitted to our trauma center from 2015 to 2021. Demographic data, mechanism of injury, findings on admission, imaging studies, procedures during hospitalization, and functional outcomes were gathered. INR with a cutoff of 1.3, platelet count less than 100 × 10⁹/L, or partial thromboplastin time greater than 40s were utilized as the markers of coagulopathy. A total of 4002 patients were included. Coagulopathy occurred in 38.1% of the patients. Age of the patients (Odds Ratio (OR) = 0.993, 95% Confidence Interval (CI) = 0.986-0.999, p = 0.028), systolic blood pressure (OR = 0.993, 95% CI = 0.989-0.998, p = 0.005), fibrinogen level (OR = 0.998, 95% CI = 0.996-0.999, p < 0.001), and hemoglobin level (OR = 0.886, 95% CI = 0.839-0.936, p < 0.001) were independently associated with coagulopathy. Furthermore, coagulopathy was independently associated with higher mortality rates and longer ICU stays. Coagulopathy had the most substantial effect on mortality of TBI patients (OR = 2.6, 95% CI = 2.1-3.3, p < 0.001), compared to other admission clinical characteristics independently associated with mortality such as fixed pupillary light reflex (OR = 1.8, 95% CI = 1.5-2.4, p < 0.001), GCS (OR = 0.91, 95% CI = 0.88-0.94, p < 0.001), and hemoglobin level (OR = 0.93, 95% CI = 0.88-0.98, p = 0.004). Early coagulopathy in TBI patients can lead to higher mortality rates. Future studies are needed to prove that early detection and correction of coagulopathy and modifiable risk factors may help improve outcomes of TBI patients.

Integrated oral care for patients with spinal cord injuries: perceptions of non-dental professionals

Purpose To understand the oral health attitudes, knowledge, and practices among non-dental professionals caring for patients with spinal cord injuries, as well as the barriers and facilitators to oral care across acute and rehabilitation hospital settings. Materials and Methods This study was a descriptive qualitative study. Nine focus groups with spinal cord injury clinicians from two Sydney hospitals were conducted (n = 35). A thematic analysis was undertaken. Results Four themes were constructed: understanding the impact of spinal cord injuries on oral health and wellbeing; limited support in the spinal cord injury unit to promote oral care; strategies that enable oral care promotion; and recommendations to expand scope in oral care and education. Although most clinicians considered oral health to be important there was a lack of guidelines to support standardised oral care practices. Barriers included lack of time, limited oral care resources, low priority and difficulty in accessing treatment. Staff were receptive to an integrated, multidisciplinary approach to oral care. Conclusion This Australian first study provides insight into spinal cord injury clinicians’ knowledge and practices of oral care. The findings will help guide future research in developing appropriate models of care to promote oral health among patients with spinal cord injuries.

Robotic assisted common bile duct exploration for management of complex gallstone disease.

Minimally invasive cholecystectomy and common bile duct exploration offers single- stage management for complex gallstone disease (cholelithiasis and choledocholithiasis). Robotic platform presents benefits in improving operative precision, which has not been extensively evaluated in the acute setting of managing complex gallstone disease, as well as in performing transcholedochal or post cholecystectomy common bile duct exploration. We report an early series of emergent and expedited robotic assisted cholecystectomy with common bile duct exploration (RC-CBDE) or robotic common bile duct exploration (R-CBDE) alone. Retrospective analysis from a specialist unit in the United Kingdom was undertaken from April 2022-September 2023 inclusive. All patients that underwent RC-CBDE or R-CBDE were included. Data was collated on patient demographics, perioperative investigations, intraoperative approach, and postoperative outcomes. Twenty-three consecutive patients were identified. Median (IQR) age was 51 (33-66) years. Median (IQR) Charlson Co-morbidity Index (CCI) was 1 (0-4). Five patients underwent operative intervention as an emergency and 18 on an expedited basis. Two patients underwent post cholecystectomy R-CBDE. Fourteen (61%) were transcholedochal and nine were transcystic (31%) CBDE. Median (IQR) bilirubin was 51 (34-253). Median (IQR) operative time was 176 (124-222) minutes. Median (IQR) post-operative length of stay was 2 (0-4) days. There were no bile leaks requiring intervention. The clearance rate of CBDS was 100%. No patients developed postoperative pancreatitis. One patient required intervention for port site hernia following RC-CBDE. One patient developed subhepatic collection post-operatively and required laparoscopic washout and placement of drains. No patients had retained stones after 3-month follow-up. Early experience confirms that RC-CBDE and R-CBDE in feasible, safe, and effective treatment for complex gallstone disease. Integrated adjuncts (intraoperative robotic ultrasound - IORUS and Firefly® - fluorescence guided surgery - FGS) and superior ergonomics of the robotic platform may assist in reducing the learning curve and increase wider uptake of this complex procedure.

Continuous thermodilution and microvascular resistance reserve during the index procedure in acute coronary syndrome without obstructive coronary artery disease: A pilot study.

In 5%-25% of non-ST-elevation acute coronary syndrome (NSTE-ACS) patients, coronary angiography reveals no obstructive coronary arteries (MINOCA). Coronary microvascular disease (CMD) is a potential causal pathophysiological mechanism in these patients and can be diagnosed by continuous thermodilution assessment. Recently, the microvascular resistance reserve (MRR) has been introduced as a novel index to assess the vasodilatory capacity of the microcirculation. However, continuous thermodilution and MRR have never been investigated in the acute setting in MINOCA patients and invasive assessment of the microcirculation in these patients are currently lacking. The objectives of the study were to investigate the incidence of CMD (MRR ≤ 2.7) in patients with MINOCA and to evaluate the feasibility and safety of continuous thermodilution-based assessment during index coronary angiography in the acute setting. This study was a prospective, observational, pilot study investigating coronary physiology in the acute setting in MINOCA patients. Patients admitted with a diagnosis of NSTE-ACS were eligible for inclusion. In total, 19 MINOCA patients were included in this analysis;the mean age was 70 ± 9 years, and 79% were females. CMD was present in 6 patients (32%). Qrest was significantly higher in the MRR ≤ 2.7 group compared to the MRR > 2.7 group (0.076 [0.057-0.100] vs. 0.049 [0.044-0.071] L/min, p = 0.03). Rµ,rest was significantly lower in the MRR ≤ 2.7 group compared to the MRR > 2.7 group (1083 [710-1510] vs. 1563 [1298-1970]WU,p = 0.04). No periprocedural complications or hemodynamic instability have occurred during continuous thermodilution assessment during the index coronary angiography. In patients admitted for MINOCA undergoing immediate coronary angiography, continuous thermodilution assessmentand MRR are feasible and safe in the acute setting, and evidence of functional CMD could be observed in one-third of the MINOCA patients.

Contextual factors and intentional rounding in acute hospitals: understanding what works, for whom, in what settings: a realist synthesis protocol.

This study aims to understand and explain the influence of contextual factors on the implementation of Intentional Rounding in acute hospitals using the realist synthesis methodology.Falls of hospital admitted patients are one of the most frequent concerns for patient safety in the acute hospital environment. The reasons why people fall are complex. International guidelines recommend a multifactorial assessment and effective prevention and management of identified risk factors in order to reduce the number of falls. Intentional Rounding (IR) is one approach for delivering this. IR is an umbrella term, understood as a structured process whereby nurses or care staff carry out regular checks with individual patients using a standardised protocol to address such issues as positioning, pain, personal needs and placement of possessions. This study will use realist synthesis to understand what works, for whom, in what circumstances, and in what settings. Realist synthesis is a theory driven interpretive approach to evidence synthesis. It is our intention to analyse IR as an intervention, which aims to enhance patient care and safety in hospital settings. The synthesis forms part of a larger implementation study examining interventions that reduce the number of falls that occur in hospitals. Search terms will include intentional rounding, purposeful rounding, comfort rounding and hourly rounding and will encompass search terms beyond IR and falls rates to avoid limiting the synthesis. This synthesis will conform to the RAMESES (realist and meta-narrative evidence synthesis group) publication and reporting quality standards. The findings will inform the next phase of an implementation study on IR in acute hospital settings, to address evidence informed enablers and barriers to IR. The results will be disseminated in a peer-reviewed journal and through presentations.

Uncovering Complexities in Reducing Aggression, Conflict and Restrictive Practices in Acute Mental Healthcare Settings: An Overview of Reviews.

Aggression, conflict and restrictive practices present complexities in acute mental health services, as do implementing service changes to reduce them. Existing published literature needs to offer more high-level guidance on the effectiveness of these service changes and their associated implementation factors. As a result, an overview of systematic reviews was undertaken to identify (i) nonpharmacological interventions to reduce conflict, aggression and restrictive practices in acute mental health settings, and (ii) their effects across different clinical outcomes. A parallel re-extraction from primary studies was then utilised (iii) to identify factors influencing successful intervention implementation. Of 124 articles sourced from nine databases and registries, four reviews were retained for the final analysis, using the direction of effect and tabular and narrative summaries. These reviews included programmes or interventions focused on inpatient adolescent, adult and older adult populations. They reported on alternative containment strategies, risk assessments, Safewards, sensory rooms and equipment, Six Core Strategy-based interventions and staff training. The overview found that a combination of interventions intended to improve relationships and reduce interpersonal conflict may help reduce aggression, conflict and restrictive practices. At the same time, stand-alone staff training and sensory rooms and equipment may have mixed effects. The quality of the evidence linking these interventions to reductions in aggression, conflict and restrictive practices is limited. Successful implementation hinges on multiple factors: intervention characteristics, preparation and planning, evaluation and monitoring, outcome interpretation, stakeholder involvement/investment, staff-related factors and contextual factors. Any implementation initiative may benefit from using pragmatic and complexity-informed research methodologies, including integrating meaningful involvement with service users, peer workers and culturally diverse groups.

Transcatheter Structural Heart Interventions in the Acute Setting: An Emerging Indication.

Structural heart disease is increasingly prevalent in the general population, especially in patients of increased age. Recent advances in transcatheter structural heart interventions have gained a significant following and are now considered a mainstay option for managing stable valvular disease. However, the concept of transcatheter interventions has also been tested in acute settings by several investigators, especially in cases where valvular disease comes as a result of acute ischemia or in the context of acute decompensated heart failure. Tested interventions include both the mitral and aortic valve, mostly evaluating mitral transcatheter edge-to-edge repair and transcatheter aortic valve implantation, respectively. This review is going to focus on the use of acute structural heart interventions in the emergent setting, and it will delineate the available data and provide a meaningful discussion on the optimal patient phenotype and future directions of the field.

Deep learning survival model predicts outcome after intracerebral hemorrhage from initial CT scan.

Predicting functional impairment after intracerebral hemorrhage (ICH) provides valuable information for planning of patient care and rehabilitation strategies. Current prognostic tools are limited in making long term predictions and require multiple expert-defined inputs and interpretation that make their clinical implementation challenging. This study aimed to predict long term functional impairment of ICH patients from admission non-contrast CT scans, leveraging deep learning models in a survival analysis framework. We used the admission non-contrast CT scans from 882 patients from the Massachusetts General Hospital ICH Study for training, hyperparameter optimization, and model selection, and 146 patients from the Yale New Haven ICH Study for external validation of a deep learning model predicting functional outcome. Disability (modified Rankin scale [mRS] > 2), severe disability (mRS > 4), and dependent living status were assessed via telephone interviews after 6, 12, and 24 months. The prediction methods were evaluated by the c-index and compared with ICH score and FUNC score. Using non-contrast CT, our deep learning model achieved higher prediction accuracy of post-ICH dependent living, disability, and severe disability by 6, 12, and 24 months (c-index 0.742 [95% CI -0.700 to 0.778], 0.712 [95% CI -0.674 to 0.752], 0.779 [95% CI -0.733 to 0.832] respectively) compared with the ICH score (c-index 0.673 [95% CI -0.662 to 0.688], 0.647 [95% CI -0.637 to 0.661] and 0.697 [95% CI -0.675 to 0.717]) and FUNC score (c-index 0.701 [95% CI- 0.698 to 0.723], 0.668 [95% CI -0.657 to 0.680] and 0.727 [95% CI -0.708 to 0.753]). In the external independent Yale-ICH cohort, similar performance metrics were obtained for disability and severe disability (c-index 0.725 [95% CI -0.673 to 0.781] and 0.747 [95% CI -0.676 to 0.807], respectively). Similar AUC of predicting each outcome at 6 months, 1 and 2 years after ICH was achieved compared with ICH score and FUNC score. We developed a generalizable deep learning model to predict onset of dependent living and disability after ICH, which could help to guide treatment decisions, advise relatives in the acute setting, optimize rehabilitation strategies, and anticipate long-term care needs.

The “Team Tree” Professional Tree of Life intervention: development and evaluation within the acute inpatient psychiatric setting

PurposeMental health staff often experience significant levels of stress working in the acute psychiatric inpatient setting. Team-building interventions can mitigate stress in health-care settings, via improvements in team-cohesion, staff interactions and communication skills. The “Tree of Life” (ToL) is a specific narrative therapy approach which uses the metaphor of a tree to facilitate the construction and sharing of strength-based stories. This study aims to describe the development of and evaluate the feasibility, acceptability and staff experiences of the “Team Tree”, an adapted Professional ToL (PToL) intervention.Design/methodology/approachA one-hour, Professional ToL intervention was designed for multidisciplinary acute inpatient staff teams working within a psychiatric hospital in London, UK. A mixed methods approach was used to evaluate the feasibility, acceptability and staff experiences of the session.FindingsParticipants were 46 multidisciplinary staff (33 women; 13 men) working across four acute psychiatric wards. The intervention was feasible to deliver and was acceptable to participants. Results showed significant improvements in self-reported mental well-being and team-cohesiveness scores post-session.Practical implicationsPsychologists face myriad barriers in working with staff teams in the acute inpatient setting. The “Team Tree” intervention was both well received by staff and practical to deliver within the challenging environment of the acute ward.Originality/valueThis adaptation of the original PToL emerged from the author’s work with distressed inpatient teams with limited time resources. To the best of the authors’ knowledge, this is the first description of this intervention using a single tree metaphor to facilitate a reflective and creative session with health-care teams.

'Giving birth on a beach': Women's experiences of using virtual reality in labour.

Birth is a normal physiological process, and many women want a natural birth. Women use a range of non-pharmacological pain relief methods to reduce labour pain intensity, to help manage labour pain and to induce relaxation. The purpose of this study was to explore the experiences of women using Virtual Reality as a non-pharmacological method of pain relief in labour. Virtual Reality has been shown to be an effective distraction technique in other acute pain settings which also reduces anxiety. This study conducted qualitative in-depth interviews postnatally with women who used Virtual Reality in labour. Thematic analysis was used to analyse the qualitative data. Nineteen women used Virtual Reality in labour. Results from interviews with nineteen women in the postnatal period identified three main themes: impact of virtual reality on experience of labour, managing the pain of labour and challenges of using virtual reality in labour. This study identified that Virtual Reality was effective as a relaxation technique and helped in pain management by the use of self-efficacy techniques. Women in this study also identified preferred virtual environments specifically to use during labour and birth. This study provides a unique and original contribution to the field of Virtual Reality in labour and birth. It also identifies Virtual Reality as an acceptable and positive experience in the management of anxiety and labour pain.

Views of Mental Health Nurses on Responding to Clinical Aggression on General Wards.

The overall aim of this study was to explore the views of mental health nurses (MHNs) about their experience of responding to workplace violence (WPV) and aggression (code greys and blacks) within acute general wards. WPV continues to pose a significant source of challenge within healthcare settings despite several initiatives that have been trialled over the years. It has the potential to impact patient care and overall staff health and well-being. Nurses play a significant role in the management of WPV; hence, it is important to understand how they respond to and manage incidents of WPV. The study design was an explorative descriptive qualitative design. Data were collected through semi-structured interviews involving n = 10 MHNs working within a mental health consultation liaison team that responds to incidents of violence and aggression (codes grey and black) in acute general wards. Participants were recruited using a convenient sampling method. Data were analysed using thematic analysis. The findings of this study highlighted the following themes: (1) Patient care (subthemes: patient frustration with hospital processes, lack of time and resources); (2) Staffing skills and confidence (subthemes: lack of adequate training, inability to intervene early and communication skills); (3) Understanding patient behaviours (subthemes: it's a psychiatry problem and zero tolerance approach). The management of WPV within acute hospital settings needs to be given due attention by healthcare services. Although a number of organisations are developing measures and guidelines to manage WPV, there is still a gap in the ability of general nursing staff to properly manage such incidences. Proper attention needs to be taken to the training of staff.

Stenting with dual-layer CGuard stent in acute sub-occlusive carotid artery stenosis and in tandem occlusions: a monocentric study

PurposeDouble-layer design carotid stents have been cast in a negative light since several investigations reported high rates of in-stent occlusions, at least in the acute setting of tandem occlusions. CGuard is a new generation double-layered stent that was designed to prevent periinterventional embolic events. The aim of this study was to analyze the safety and efficacy of the CGuard in emergent CAS and for the acute treatment of tandem occlusions in comparison with the single-layer Carotid Wallstent (CWS) system.MethodsAll patients who underwent CAS with CGuard or CWS after intracranial mechanical thrombectomy (MT) between 11/2018 and 12/2022 were identified from our local thrombectomy registry. Clinical, interventional and neuroimaging data were analyzed. Patency of the stent was assessed within 72 h. Intracranial hemorrhage and modified Rankin score (mRS) at discharge were the main endpoints.ResultsIn total, 86 stent procedures in 86 patients were included (CWS: 44, CGuard: 42). CGuard had a lower, but not statistically significant rate (p = 0.431) of in-stent occlusions (n = 2, 4.8%) when compared to the CWS (n = 4, 9.1%). Significant in-stent stenosis was found in one case in each group. There was no statistically significant difference in functional outcome at discharge between the two groups with a median mRS for CGuard of 2 (IQR:1–5) vs. CWS 3 (IQR:2–4).ConclusionIn our series, the rate of in-stent occlusions after emergent CAS was lower with the dual-layer CGuard when compared to the monolayer CWS. Further data are needed to evaluate the potential benefit of the design in more detail.

Automated control of Impella maintains optimal left ventricular unloading during periods of unstable hemodynamics and prevents myocardial damage in acute myocardial infarction

BackgroundLeft ventricular (LV) unloading by Impella, an intravascular microaxial pump, has been shown to exert dramatic cardioprotective effects in acute clinical settings of cardiovascular diseases. Total Impella support (no native LV ejection) is far more efficient in reducing LV energetic demand than partial Impella support, but the manual control of pump speed to maintain stable LV unloading is difficult and impractical. We aimed to develop an Automatic IMpella Optimal Unloading System (AIMOUS), which controls Impella pump speed to maintain LV unloading degree using closed-feedback control. We validated the AIMOUS performance in an animal model. MethodsIn dogs, we identified the transfer function from pump speed to LV systolic pressure (LVSP) under total support conditions (n = 5). Using the transfer function, we designed the feedback controller of AIMOUS to keep LVSP at 40 mmHg and examined its performance by volume perturbations (n = 9). Lastly, AIMOUS was applied in the acute phase of ischemia-reperfusion in dogs. Four weeks after ischemia-reperfusion, we assessed LV function and infarct size (n = 10). ResultsAIMOUS maintained constant LVSP, thereby ensuring a stable LV unloading condition regardless of volume withdrawal or infusion (±8 ml/kg from baseline). AIMOUS in the acute phase of ischemia-reperfusion markedly improved LV function and reduced infarct size (No Impella support: 13.9 ± 1.3 vs. AIMOUS: 5.7 ± 1.9%, P < 0.05). ConclusionsAIMOUS is capable of maintaining optimal LV unloading during periods of unstable hemodynamics. Automated control of Impella pump speed in the acute phase of ischemia-reperfusion significantly reduced infarct size and prevented subsequent worsening of LV function.

Diagnostic test accuracy of screening tools for the detection of neurocognitive disorders in older adults post-trauma: A protocol for a systematic review

Background Neurocognitive disorders (NCDs), including delirium, cognitive impairment, or dementia are prevalent in up to 39% of older adults in acute care, particularly older trauma patients. Undiagnosed NCDs result in poor outcomes, such as increased incidence of depressive symptoms, longer length of stay, and mortality. Objective This study aims to identify the diagnostic test accuracy of screening tools for the detection of NCDs in older trauma patients in acute settings. Design Systematic review protocol. Literature search Electronic databases (MEDLINE, Embase, CINAHL, PsycInfo, Cochrane Library) will be searched for journal articles. Search terms related to NCDs, delirium and cognitive screening tools, and diagnostic accuracy will be included. Study selection criteria Cross-sectional, prospective, or retrospective cohort studies of adults aged ≥60 post-trauma, in an acute setting, will be included where the study aimed to validate a screening tool for detection of 1) delirium or 2) cognitive impairment, or dementia against a reference standard of a clinical decision, based on standardised diagnostic criteria or a validated tool. Data synthesis Two review authors will conduct study selection, data extraction, and appraisal. Data will be extracted based on the Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy Studies (PRISMA-DTA) checklist. Studies will be assessed for methodological quality by two independent review authors using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Narrative summaries will be generated describing risk of bias and concerns regarding applicability. Quantitative synthesis of study findings will be conducted. Conclusion This systematic review will aim to identify screening tools with the best diagnostic accuracy for detection of 1) delirium and 2) cognitive impairment or dementia in adults aged ≥60 post-trauma in acute care settings. Results will inform clinical practice to enhance the probability of patients with NCDs receiving appropriate care and management. Registration PROSPERO https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024518730 (11/03/2024).