Shock Therapy Research Articles

Automated detection of shockable ECG signals: A review

• Shockable and non-shockable ECG signals are analyzed. • A review study for shockable ECG signal recognition is discussed. • Unique bispectrum and recurrence plots are proposed for shockable and non-shockable ECG signals. • Performance of nonlinear features for differentiating shockable and non-shockable. • ECG signals is compared. Sudden cardiac death from lethal arrhythmia is a preventable cause of death. Ventricular fibrillation and tachycardia are shockable electrocardiographic (ECG)rhythms that can respond to emergency electrical shock therapy and revert to normal sinus rhythm if diagnosed early upon cardiac arrest with the restoration of adequate cardiac pump function. However, manual inspection of ECG signals is a difficult task in the acute setting. Thus, computer-aided arrhythmia classification (CAAC) systems have been developed to detect shockable ECG rhythm. Traditional machine learning and deep learning methods are now progressively employed to enhance the diagnostic accuracy of CAAC systems. This paper reviews the state-of-the-art machine and deep learning based CAAC expert systems for shockable ECG signal recognition, discussing their strengths, advantages, and drawbacks. Moreover, unique bispectrum and recurrence plots are proposed to represent shockable and non-shockable ECG signals. Deep learning methods are usually more robust and accurate than standard machine learning methods but require big data of good quality for training. We recommend collecting large accessible ECG datasets with a meaningful proportion of abnormal cases for research and development of superior CAAC systems.

RR interval variability in the evaluation of ventricular tachycardia and effects of implantable cardioverter defibrillator therapy.

BackgroundAn implantable cardioverter defibrillator (ICD) is the most reliable therapeutic device for preventing sudden cardiac death in patients with sustained ventricular tachycardia (VT). Regarding its effectiveness, targeted VT is defined based on the tachyarrhythmia cycle length. However, variations in RR interval variability of VTs may occur. Few studies have reported on VT characteristics and effects of ICD therapy according to the RR interval variability. We aimed to identify the clinical characteristics of VTs and ICD therapy effects according to the RR interval variability.MethodsWe analyzed 821 VT episodes in 69 patients with ICDs or cardiac resynchronization therapy defibrillators. VTs were classified as irregular when the difference between two successive beats was >20 ms in at least one of 10 RR intervals; otherwise, they were classified as regular. We evaluated successful termination using anti‐tachycardia pacing (ATP)/shock therapy, spontaneous termination, and acceleration between regular and irregular VTs. The RR interval variability reproducibility rates were evaluated.ResultsRegular VT was significantly more successfully terminated than irregular VT by ATP. No significant difference was found in shock therapy or VT acceleration between the regular and irregular VTs. Spontaneous termination occurred significantly more often in irregular than in regular VT cases. The reproducibility rates of RR interval variability in each episode and in all episodes were 89% and 73%, respectively.ConclusionsATP therapy showed greater effectiveness for regular than for irregular VT. Spontaneous termination was more common in irregular than in regular VT. RR interval variability of VTs seems to be reproducible.

The mechanical support of cardiogenic shock.

Cardiogenic shock (CS) therapy involving catecholamines, inotropes, fluids and revascularization is often insufficient, and short-term mortality remains 50%. Different treatment algorithms and mechanical circulatory support devices (MCS) have been increasingly used in the treatment of CS. Coronavirus disease 2019 (COVID-19) pandemic is a major challenge faced by intensive care medicine providers inevitably influencing also CS management. There is a lack of prospective data as well as international consensus regarding CS classification, patient risk stratification, and MCS use. Veno-arterial extracorporeal membrane oxygenation is considered the first line MCS in refractory CS and Impella the MCS of choice for the left ventricle unloading. Several ongoing randomized trials will provide much-needed evidence for MCS use in the coming years. COVID-19 infection is associated with several cardiovascular disorders complicated by CS and more data regarding the prevalence and mortality of CS during COVID-19 infection are needed. This review summarizes current trends in the use of MCS in CS and discusses differences in CS management during the COVID-19 pandemic. Careful patient selection, early MCS initiation, and comprehensive intensive care by experienced team is key to successful outcome in patients with refractory CS.

Long-term clinical outcome of cardiogenic shock patients undergoing Impella CP treatment vs. standard of care

Abstract Funding Acknowledgements Type of funding sources: None. Background The number of patients treated with the mechanical circulatory support device Impella Cardiac Power (CP) for cardiogenic shock is steadily increasing. The aim of this study was to investigate long-term survival and complications related to this modality. Methods Patients undergoing Impella CP treatment for cardiogenic shock were retrospectively enrolled and matched with cardiogenic shock patients not treated with mechanical circulatory support between 2010 and 2020. Data were collected from the cardiogenic shock registry of our university hospital. Results 68 patients with refractory cardiogenic shock without mechanical circulatory support were matched with 68 patients treated with Impella CP. At presentation, the mean age was 67 ± 14 years with 82% being male in the group without support and 68 ± 14 years (p = 0.65) with 77% being male (p = 0.52) in the group with Impella. There was no significant difference in the rate of cardiac arrest (57% vs. 54%, p = 0.86) and myocardial infarction was the predominant cause of cardiogenic shock in both groups (66% vs. 74%, p = 0.34). A total of 46% of patients without cardiocirculatory support and 54% of patients with Impella support died during the first month (p = 0.32). After one year, mortality rates were similar in both groups (53% in conventional vs. 59% in Impella CP group, p = 0.51) as was mortality rate at long-term 5-years follow-up (73% in conventional vs. 72% in Impella CP group, p = 0.50). The rate of clinically significant bleedings during ICU stay was much lower in the conventional group than in the Impella support group (25% vs. 42%, p = 0.03). Conclusion In this small observational and non-randomized analysis no difference in long-term outcome between patients treated with Impella CP vs. guideline directed cardiogenic shock therapy without mechanical circulatory support could be detected. Care must be taken regarding the high rate of bleeding and vascular complications when using Impella CP. Large, adequately powered studies are urgently needed to investigate the efficacy and safety of Impella CP in cardiogenic shock.

Central hemodynamic monitoring in patients with cardiogenic shock

Cardiogenic shock is the pathology most commonly encountered by intensive care physicians. Its frequency averages 410% in STEMI (ST-elevation myocardial infarction) patients and 24% in NONSTEMI (non-ST-elevation myocardial infarction) patients. Effective shock therapy is impossible without understanding the hemodynamic mechanisms of its occurrence. Many authors emphasize that cardiac output is the most important indicator of cardiac function, which necessitates its monitoring. Meanwhile, the cardiac output monitoring is associated with a number of difficulties, including those related to the technology of recording this function. In this article, the authors emphasize the importance of measuring central hemodynamic parameters in patients with predominantly cardiogenic shock. We have tried to structure the knowledge about different techniques of central hemodynamics monitoring, considered advantages and disadvantages of each of them. We believe that the data obtained by hemodynamic monitoring should be closely studied and used, because sometimes multidirectional mechanisms may be involved in the genesis of shock; therefore, therapy should be based on the data obtained in a particular patient.

Management of Implantable Cardioverter-Defibrillators during Pregnancy-A Systematic Review.

Background: With the advent of implantable cardioverter-defibrillator (ICD) technology in recent decades, patients with inherited or congenital cardiomyopathy have a greater chance of survival into adulthood. Women with ICDs in this group are now more likely to reach reproductive age. However, pregnancy represents a challenge for clinicians, as no guidelines for the treatment of pregnant women with an ICD are currently available. Methods: To analyze this issue, we performed a systematic screening of the literature using the keywords: pregnancy with ICD, lead fracture in pregnancy, lead thrombi in pregnancy, ventricular tachycardia in pregnancy, inappropriate shocks in pregnancy, ICD discharge in pregnancy and ICD shock in pregnancy. Of 1101 publications found, 27 publications were eligible for further analysis (four retrospective trials and 23 case reports). Results: According to physiological changes in pregnancy, resulting in an increase in heart rate and cardiac output, a vulnerability for malignant arrhythmias and device-related complications in ICD carriers might be suspected. While the literature is limited on this issue, maternal complications including arrhythmia burden with following ICD therapies, thromboembolic events and lead complications as well as inappropriate shock therapy have been reported. According to the limited available studies, associated risk seems not to be more frequent than in the general population and depends on the underlying cardiac pathology. Furthermore, worsening of heart failure and related cardiovascular disease have been reported with associated risk of preterm delivery. These observations are exaggerated by restricted applications of diagnostics and treatment due to the risk of fetal harm in this population. Conclusions: Due to limited data on management of ICDs during pregnancy, further scientific investigations are required. Consequently, careful risk assessment with individual risk evaluation and close follow ups with interdisciplinary treatment are recommended in pregnant ICD carriers.

Development of a field artificial intelligence triage tool: Confidence in the prediction of shock, transfusion, and definitive surgical therapy in patients with truncal gunshot wounds.

In-field triage tools for trauma patients are limited by availability of information, linear risk classification, and a lack of confidence reporting. We therefore set out to develop and test a machine learning algorithm that can overcome these limitations by accurately and confidently making predictions to support in-field triage in the first hours after traumatic injury. Using an American College of Surgeons Trauma Quality Improvement Program-derived database of truncal and junctional gunshot wound (GSW) patients (aged 16-60 years), we trained an information-aware Dirichlet deep neural network (field artificial intelligence triage). Using supervised training, field artificial intelligence triage was trained to predict shock and the need for major hemorrhage control procedures or early massive transfusion (MT) using GSW anatomical locations, vital signs, and patient information available in the field. In parallel, a confidence model was developed to predict the true-class probability (scale of 0-1), indicating the likelihood that the prediction made was correct, based on the values and interconnectivity of input variables. A total of 29,816 patients met all the inclusion criteria. Shock, major surgery, and early MT were identified in 13.0%, 22.4%, and 6.3% of the included patients, respectively. Field artificial intelligence triage achieved mean areas under the receiver operating characteristic curve of 0.89, 0.86, and 0.82 for prediction of shock, early MT, and major surgery, respectively, for 80/20 train-test splits over 1,000 epochs. Mean predicted true-class probability for errors/correct predictions was 0.25/0.87 for shock, 0.30/0.81 for MT, and 0.24/0.69 for major surgery. Field artificial intelligence triage accurately identifies potential shock in truncal GSW patients and predicts their need for MT and major surgery, with a high degree of certainty. The presented model is an important proof of concept. Future iterations will use an expansion of databases to refine and validate the model, further adding to its potential to improve triage in the field, both in civilian and military settings. Prognostic, Level III.

Cardioprotective shock management: monitoring and supportive therapies.

Cardiogenic shock is a highly lethal syndrome, leading to rapid death or secondary multiorgan damage, but current shock therapies, including mechanical support devices, also have a significant side effect profile. The overarching goal of shock therapy is ensuring long-term survival with good quality of life. This implies averting death, modifying the disease course by promoting heart recovery and avoiding additional cardiac damage, protecting other organs, and circumventing complications. Monitoring and supportive therapies are subordinate to these goals. Rather than merely following preconceived notions, the rapid evolution in mechanical support technology requires iterative and critical review of the benefits of current procedures, protocols and drugs in view of their overall contribution to the therapeutic goals. This article discusses various monitoring and supportive pharmaceutical modalities typically used in patients with cardiogenic shock requiring mechanical support.

Left bundle branch block without a typical contraction pattern is associated with increased risk of ventricular arrhythmias in cardiac resynchronization therapy patients.

Cardiac resynchronization therapy (CRT) reduces the risk of ventricular arrhythmias (VA) in heart failure (HF) patients with left bundle branch block (LBBB) while the effect is less clear among non-LBBB patients. This study aimed to investigate if absence of LBBB features whether by echocardiography or strict ECG criteria would identify patients at risk of developing VA in a cohort with LBBB according to conventional ECG criteria. Two hundred six CRT candidates were prospectively included from 2 centers. Prior to CRT presence of a typical LBBB contraction pattern was identified using longitudinal strain in the apical 4-chamber view. All preimplantation ECGs were categorized as LBBB or non-LBBB according to Strauss´ strict criteria. Primary end-point was defined as any appropriate antitachycardia pacing (ATP) or shock therapy within 2years after CRT implantation. A total of 129 (63%) patients had a typical LBBB contraction pattern, while 134 (66%) met the strict ECG criteria. Over 2years, 45 patients (22%) experienced VA. Absence of a typical LBBB contraction pattern was independently associated with an increased risk of VA (hazard ratio ([HR] 1.89; 95% CI 1.04 to 3.44; p: 0.036). Strict LBBB was not independently associated with the occurrence of VA. Fulfilling neither strict ECG nor echocardiographic criteria for LBBB was associated with a 3.3-fold increase in risk of VA ([HR] 3.34; 95% CI 1.75 to 6.94; (p < 0.001). The risk of VA was almost 2-fold higher if a typical LBBB contraction pattern was absent prior to CRT.

Guidance of Clinical Magnet Application of Inhibition of Inappropriate Shock in Patient of Subcutaneous Implantable Cardioverter Defibrillators: A Review of the Literature

Background: The subcutaneous implantable cardioverter defibrillator (S-ICD) represents a major advancement in ICD technology in the last 10 years. During the experience with the 1nd generation of S-ICD, the IAS rate was 4,5% to 25% and with 2nd generation and 3nd generation of S-ICD the IAS rate was 3.1% at one year. Indeed, in the hospital and out of hospital emergency situations in presence of IAS it is mandatory to suspend the shock therapy.

A Case of Successful Ketamine Treatment after ECT Failure in a patient with Major Depressive Disorder

<h3>Introduction</h3> Electroconvulsive therapy (ECT) has long been a treatment modality of choice for treatment resistant depression. It remains one of the most effective treatments in psychiatry for a multitude of diseases. However, if patients fail ECT there is a lack of robust options for alternative treatments. This case describes a patient who was initially treated with ECT with no response after several treatments and subsequently transitioned to IV ketamine. Once started on ketamine patient showed a significnat improvement in his depressive symptoms and was able to be discharged from an inpatient psychiatric unit. Mr. X is a 70 year old male with a history of major depressive disorder and three prior suicide attempts. He had multiple recent life stressors, including a spouse diagnosed with cancer and being unable to work after back surgery which significantly contributed to his depression. He was admitted to the psychiatric hospital after an attempted overdose. He was started on escitalopram and buproprion XL, which were titrated to max doses throughout his hospitalization. Given his history of incomplete response with medication, his severe depression, and his high suicide risk, aggressive treatment was warranted. ECT was initiated and he underwent 5 treatments of right unilateral, 2 treatments of bifrontal, and 1 treatment of bitemporal. Throughout the course of ECT he had a lack of seizures despite flumazenil, hyperventilation, various induction agents (including ketamine) and pharmacology. During that time he was not getting out of bed, reporting consistently depressed mood, amotivated, and apathetic. He also began noticing some increased cognitive difficulties with the bifrontal and bitemporal ECT treatments. He ultimately was deemed an ECT failure after 8 treatments with no response. Given his continued depression and failure of ECT, it was decided to attempt IV ketamine infusions as the next intervention for his depression. <h3>Methods</h3> A literature review was conducted searching for Ketamine vs ECT treatment for depression and suicidality using MESH terms of "(Depression) AND (Suicidal behavior) AND (Electroconvulsive therapy OR Electroshock therapy OR Shock therapy OR Electroshock OR Shock treatment OR Convulsive therapy OR Electric shock therapy OR Electric Convulsive therapy OR ECT) AND Ketamine" and "(Depression) AND (Suicidality) AND (Electroconvulsive therapy OR Electroshock therapy OR Shock therapy OR Electroshock OR Shock treatment OR Convulsive therapy OR Electric shock therapy OR Electric Convulsive therapy OR ECT) AND Ketamine." Additional literature regarding Ketamine for treatment resistant depression was searched for using MESH terms of "(Ketamine OR CI-581 OR CI 581 OR CI581 OR Ketalar OR Ketaset OR Ketanest OR Calipsol OR Kalipsol OR Calypsol) AND (therapy OR medical plan OR treatment OR regimen) AND (treatment resistant depression OR therapy resistant depression OR TRD OR refractory depression)." <h3>Results</h3> After initiation of ketamine Mr. X noticed an immediate improvement. He was given 3 total treatments while inpatient with significant clinical improvment noted after each treatment. He was noted to be more engaged, had improved eye contact, and was reporting improvment in his mood. He was also more active, and was noted to be consistently out of bed ambulating with his walker. After the 3 treatments inpatient he was deemed psychiatrically stable for discharge with the plan to continue an acute course of treatment post discharge. He received 2 more treatments after discharge as an outpatient before ultimately being lost to follow up. Electroconvulsive Therapy continues to show a robust response rate of approximately 80%, with remission in about 75% of cases. Even with these response rates, there is a significant patient population that will not respond to ECT. Research has shown that ketamine can have an immediate response of up to or greater than 70% of patietns within the 24 hours post-infusion. Duration of response is varied, though has been found to be present in about 50–70% of patients. However, there has not been significant published research looking into response to ketamine post ECT failure. <h3>Conclusions</h3> Mr. X is a prime example of the ongoing difficulties in treating patients with treatment resistant depression who do not respond to ECT. This case shows that after ECT failure it is appropriate to attempt treatment with ketamine barring the patient having any contraindications for treatment. Given that there is little published data regarding the response of patients who have failed ECT but subsequently respond to ketamine infusions, this case is an attempt to add to the literature in that regard. <h3>Funding</h3> None

Electroconvulsive Therapy in Multiple Sclerosis: A Review of Current Evidence.

To review the published literature over the last 5 years on the use of electroconvulsive therapy (ECT) in multiple sclerosis (MS), focusing on efficacy, safety, and tolerability. MS commonly has neuropsychiatric comorbidity. ECT is used in MS for severe and life-threatening forms of mental illness when other treatment options have failed or when a rapid response is required. English-language literature published in the last 5 years (January 2015-June 2, 2020) was searched using the terms: ECT, electroconvulsive therapy, shock therapy, electroshock therapy, electroconvulsive therapies, multiple sclerosis, chronic progressive multiple sclerosis, acute relapsing multiple sclerosis, and multiple sclerosis, relapsing and remitting. KnowledgeShare, a National Health Service library application providing updates on evidence-based practice, was used along with EMBASE, PsycInfo, MEDLINE, PubMed, the TRIP database (which offers a complete and updated list of evidence-based online resources), HDAS (Healthcare Databases Advanced Search), CRDWeb (Centre for Reviews and Dissemination), and the Cochrane Library. Reference lists of articles identified in the search were also reviewed. Our initial search revealed 30 articles of potential relevance. However, after individually evaluating these articles, only 6 case studies and 1 review article detailing the use of ECT in MS were included. The studies were analyzed by both authors to obtain clinical information relevant to meeting the objectives of the review. The efficacy and safety in using ECT for MS is derived only from case series and case reports. There were no controlled trials or systematic reviews, and the evidence collated was of low quality. The consensus is that ECT is an effective treatment for specific mental disorders in MS including catatonia. We have used ECT successfully in our clinic for patients with MS. However, there are concerns about the potential effects of ECT on neurologic and cognitive function. There are also possible risks with using anesthetic agents and particularly neuromuscular blockers.

Possibilities and safety of physiotherapy in patients with implanted cardiac devices

Widespread implantation of cardiac devices, i.e. cardiac pacemakers, cardioverter-defibrillators and cardiac resynchronisation devices improved patients survival. It has resulted in increase in number of ageing patients with cardiac devices who need physiotherapeutic treatment due to accompanied comorbidities. Hence the study of the interaction between functions of cardiac devices and physiotherapeutic treatment techniques is particularly relevant. The use and safety of physiotherapeutic treatment techniques producing electromagnetic field which in turn eventually cause harm of the cardiac devices are being discussed in present review article. The possible adverse effects of such interaction are abrupt failure to stimulate or triggering of shock therapy with consequent arrhythmic events including cardiac arrest. The technical characteristics particularly associated with electromagnetic interference are discussed here in detail. The attention is also payed to analysis of possible causes and effects of electromagnetic interference and safety measures as well.

Search for Effective Governments in Post-Soviet Russia While Excluding the Factor of World Oil Prices from the Results of the Country’s Economic Development

The method of multi-criteria assessment of economic development based on an econometric model with the identification of production, market and institutional factors in relation to the parameters of economic growth and development risks is developed. The methodology is applied to the study of actual data on the economic development of post-Soviet Russia, which allowed us to obtain objective assessments of the activities of individual governments on a large set of criteria: oil-dependent, oil-dependent and diversifying, progressive, regressive and passive, conservative and destructive, managed and unmanaged development, etc.both in terms of growth and development risks, as well as individual development factors. The article describes the parameters of economic development during periods of shock therapy, radical reforms, post-devaluation recovery, building a "vertical of power" and "nationalization of the elite". It is concluded that the last periods only preserved the institutionally degraded society, but did not ensure its development. The period 2004-2008 is the only one when a positive purposeful impact of the government on development risk was revealed, namely, it was organized to reduce the fluctuation of economic growth during the period of rising oil prices. There were no positive targeted effects of governments on economic growth.

Left intraventricular pressure gradient in hypertrophic cardiomyopathy patients receiving implantable cardioverter-defibrillators for primary prevention

BackgroundConventional risk factors for sudden cardiac death (SCD) justify primary prevention through implantable cardioverter-defibrillator (ICD) implantation in hypertrophic cardiomyopathy (HCM) patients. However, the positive predictive values for these conventional SCD risk factors are low. Left ventricular outflow tract obstruction (LVOTO) and midventricular obstruction (MVO) are potential risk modifiers for SCD. The aims of this study were to evaluate whether an elevated intraventricular pressure gradient (IVPG), including LVOTO or MVO, is a potential risk modifier for SCD and ventricular arrhythmias requiring ICD interventions in addition to the conventional risk factors among HCM patients receiving ICDs for primary prevention.MethodsWe retrospectively studied 60 HCM patients who received ICDs for primary prevention. An elevated IVPG was defined as a peak instantaneous gradient ≥ 30 mmHg at rest, as detected by continuous-wave Doppler echocardiography. The main outcome was a composite of SCD and appropriate ICD interventions, which were defined as an antitachycardia pacing or shock therapy for ventricular tachycardia or fibrillation. The Cox proportional hazards model was used to assess the relationships between risk factors and the occurrence of SCD and appropriate ICD interventions.ResultsThirty patients met the criteria of elevated IVPG (50%). During the median follow-up period of 66 months, 2 patients experienced SCD, and 10 patients received appropriate ICD interventions. Kaplan–Meier curves showed that the incidence of the main outcome was higher in patients with an IVPG ≥ 30 mmHg than in those without an IVPG ≥ 30 mmHg (log-rank P = 0.03). There were no differences in the main outcome between patients with LVOTO and patients with MVO. The combination of nonsustained ventricular tachycardia (NSVT) and IVPG ≥ 30 mmHg was found to significantly increase the risk of the main outcome (HR 6.31, 95% CI 1.36–29.25, P = 0.02). Five patients experienced ICD implant-related complications.ConclusionsOur findings showed that a baseline IVPG ≥ 30 mmHg was associated with an increased risk of experiencing SCD or appropriate ICD interventions among HCM patients who received ICDs for primary prevention. Combined with NSVT, which is a conventional risk factor, a baseline IVPG ≥ 30 mmHg may be a potential modifier of SCD risk in HCM patients.

Sepsis and Septic Shock; Current Treatment Dilemma and Role of Stem Cell Therapy in Pediatrics

Context: Sepsis’s primary therapy consists of antibiotics therapy, supportive therapies, and source control of infection. The failure rate of this approach is about 20 - 40%. The widespread use of antibiotics has caused multiple drug resistance in primary etiological agents of sepsis in community-acquired and healthcare-associated infections. In the absence of new antibiotic options, alternative treatment modalities seem necessary. Evidence Acquisition: Herein, we have reviewed and discussed current problems with sepsis management and stem cell therapy in sepsis, preclinical, experimental studies, and early-phase clinical trials using stem cells to treat sepsis. In the preparation of the paper, PubMed, Web of Science Core Collection (Clarivate), Scopus, and the web address (www.clinicaltrials.gov) were searched by the keywords (sepsis and cell therapy, septic shock, and cell therapy). Results: After the inclusion of criteria, we reviewed 301 original articles. Few articles were found for phase II and phase III clinical trials. Eighty-three articles were included in the current review article. Besides problems with infection source control, the host immune response to the infection enumerated for primary underlying pathophysiologic dysregulation of sepsis and complicated the treatment. Mesenchymal stem cells (MSCs) therapy offers a promising treatment option for sepsis. Indeed, immunomodulatory properties, antimicrobial activity, the capacity of protection against organ failure, enhance the resolution of tissue injury, tissue repair, and restoration after sepsis confer MSCs with a significant advantage to treat the immune and inflammatory dysfunctions associated with severe sepsis and septic shock. Conclusions: It seems that MSCs therapy exhibits an appropriate safety index. Future trials should focus on strengthening study quality, reporting MSCs’ therapeutic effects and adverse events. Although early clinical trials seem promising and have beneficial effects, we need more controlled clinical studies, especially in phases II and III.

The Current State of Knowledge on the Clinical and Methodological Aspects of Extracorporeal Shock Waves Therapy in the Management of Post-Stroke Spasticity—Overview of 20 Years of Experiences

In many patients after stroke, spasticity develops over time, resulting in a decrease in the patient’s independence, pain, worsening mood, and, consequently, lower quality of life. In the last ten years, a rich arsenal of physical agents to reduce muscle tone such as extracorporeal shock therapy (ESWT) wave has come through. The aim of this narrative review article is to present the current state of knowledge on the use of ESWT as a supplement to the comprehensive rehabilitation of people after stroke suffering from spasticity. The PubMed and PEDro databases were searched for papers published in English from January 2000 to December 2020, 22 of which met inclusion criteria for clinical studies related to post-stroke spasticity management with ESWT. A total of 22 studies including 468 post-stroke patients—11 reports with the upper limb (267 patients) and 10 reports within the lower limb (201 patients), as well as one report including both upper and lower limb. We focused our attention on clinical and methodological aspects. Therefore, we performed the assessment of enrolled studies in terms of methodological quality using the PEDro and level of evidence using the National Institute for Health and Clinical Excellence (NICE) guidelines. Furthermore, we indicated implications for clinical practice in using ESWT for post-stroke spasticity management. Moreover, we discussed a suggestion for future research directions. In conclusion, an ESWT effectively reduces muscle tone in people with spastic limb after stroke. Further, ESWT is safe and free of undesirable side effects. The mechanism of action of ESWT on muscles affected by spasticity is still unknown. To date, no standard parameters of ESWT in post-stroke spasticity regarding intensity, frequency, location, and the number of sessions has been established. Further research, meeting the highest standards, is needed to establish uniform muscle stimulation parameters using ESWT.

‘Shock Therapy’ and The Criminal Justice Casualties of Covid-19

Covid-19 poses the greatest threat to the poor and to those with existing vulnerabilities. This meant that the criminal justice system was especially vulnerable to its ravages. The backlog of crimi...

Unique technique to relieve left ventricular assist device electromagnetic interference with an implantable cardioverter defibrillator

We introduced a simple technique to eliminate electromagnetic interference between a left ventricular assist device (LVAD) and an implantable cardioverter defibrillator (ICD). A 43-year-old male with heart failure and a reduced ejection fraction who had an ICD presented with decompensated heart failure and received an LVAD as a bridge to transplant. Remote monitoring showed persistent atrial fibrillation causing an inappropriate ICD shock leading to a decision to disable shock therapies. However, an in-office interrogation was unsuccessful due to electromagnetic interference. Patient was instructed to extend his arm above his head on the ipsilateral side of the ICD, thus increasing the distance between LVAD and ICD, eliminating the interaction to allow reprogramming of the device.

Normal versus half-normal saline in the treatment of children with diabetic ketoacidosis

ObjectiveThis study aims to determine the effect of 0.9% saline (NS) versus 0.45% saline (half NS) on blood pressure and serum electrolytes in children with diabetic ketoacidosis.Patients and methodsThis is a cross-sectional prospective comparative study carried out on 105 patients (1–18 years) from those admitted to the pediatric ICU of Al-Zahraa University Hospital from March 2017 to August 2019. Cases were divided into three groups (35 in each group). Group I patients received a shock, deficit, and maintenance therapy with NS. Group II patients received a shock therapy NS along with deficit and maintenance therapy with half NS. Group III patients received a shock, deficit, and maintenance therapy with half NS.ResultsThere were no hypotensive cases among all patients. There was a significant decrease in mean arterial blood pressure in the three groups after treatment. There was a significant increase in serum corrected sodium level in group I after treatment, whereas there was a significant decrease in its level in groups II and III. Serum potassium level showed an insignificant decrease after treatment in all groups. Blood glucose level significantly decreased after treatment in the same group, but in comparison with other groups, the differences were insignificant. Serum osmolality significantly decreased after treatment in all groups. pH significantly increased after treatment in each group, but in a comparison between groups, there were insignificant differences. Group I had the longest pediatric ICU stay.ConclusionsOur patients continue to maintain normal or even have higher blood pressure levels with no hypotensive cases. The mean arterial blood pressure significantly decreased after treatment with intravenous fluids, especially in the group that received half NS. Rehydration with half NS results in decreased corrected sodium and more decrease in effective serum osmolality.