Background: Although pregnancy imposes extra risk in patients with pulmonary arterial hypertension (PAH), hemodynamic characteristics vary between PAH patients with and without cardiac shunts. However, previous studies did not take hemodynamic differences in PAH patients into consideration for pregnancy outcome analysis. We aimed to identify predictors for peripartum outcome of PAH patients without/with cardiac shunt.
Methods: We retrospectively analyzed the medical records of PAH gravidae parturiated by cesarean delivery (C-section) from 4 hospitals. Maternal death and major adverse cardiac events (MACEs) occurring during pregnancy or within 6 weeks postpartum were defined as composite end points. Risk factors for end points were analyzed separately in patients with and without cardiac shunt. The effect of general anesthesia on MACEs and maternal death was analyzed considering cardiac shunts.
Results: One hundred and eighty-one PAH gravidae were included, of whom 85 had PAH without cardiac shunt and 96 with shunt. Patients who met combined end points were 19/85 in those without shunt compared with 23/96 in those with shunt. The mortality rates were 11.8% and 9.4%, respectively. Both World Health Organization functional class (WHO-FC) III/IV and general anesthesia were predictors for gravidae without shunt, whereas only WHO-FC III/IV was a predictor for gravidae with shunt. General anesthesia increased the MACE risk (odds ratio, 9.000; 95% confidence interval, 2.628-30.820) and maternal mortality (odds ratio, 11.000; 95% confidence interval, 2.595-46.622; P = 0.039) in patients without cardiac shunt but not in those with shunt during C-section.
Conclusion: All PAH gravidae with WHO-FC III/IV are at high risk and should receive intensive care. General anesthesia should be avoided during C-section for PAH gravidae without a cardiac shunt.
Background: To compare the differences between the Kidney Disease Improving Global Outcomes (KDIGO) criteria of the 48-hour window (early acute kidney injury [AKI], 3-5 day window [middle AKI], and 6-7 day window [late AKI]) in the diagnosis of AKI, as well as the relationship between the diagnosis time windows and 90-day mortality.
Methods: We conducted a retrospective cohort study. All elderly patients admitted to the Geriatric Department of the Chinese PLA General Hospital between 2007 and 2018 were evaluated for AKI during their hospital stay. Patients with AKI were divided into early, middle, and late AKI groups according to the time of diagnosis. Statistical analyses were performed using SPSS 21.0 statistical software. Continuous parametric variables are expressed as the means ± standard deviations (SDs), and continuous nonparametric variables are presented as the medians with interquartile ranges (25th and 75th percentiles). Categorical variables are presented as numbers (n) or percentages (%). Group comparisons were conducted using one-way analysis of variance or the Kruskal-Wallis H test for continuous variables and Pearson’s chi-square or Fisher’s exact test for categorical variables. Logistic regression analyses and a forward stepwise selection method were used to identify risk factors associated with AKI diagnosis time windows and 90-day mortality.
Results: During the follow-up period, 1847 patients were enrolled. Overall, 22.4% of the patients (413/1847) developed early AKI, 7.3% (134/1847) developed middle AKI, and 10.7% (197/1847) developed late AKI. Risk factors for early AKI included age, hypoalbuminemia, low prealbumin level, and the need for mechanical ventilation; middle AKI was significantly associated with age, low prealbumin, low hemoglobin, and the need for mechanical ventilation, whereas late AKI was closely associated with age, low baseline estimated glomerular filtration rate, low prealbumin, and low hemoglobin. In the multivariable-adjusted analysis, AKI time windows (early AKI, odds ratio [OR]: 6.069; P < 0.001; middle AKI, OR: 5.000; P < 0.001) and late AKI (OR: 2.847; P < 0.001) were more strongly associated with higher 90-day mortality than non-AKI.
Conclusion: Clinical differences and risk factors for AKI in elderly patients depend on the definition used. A better understanding of how AKI develops during different diagnostic windows may lead to improved outcomes.
Background: The decision to withhold or withdraw life-sustaining treatments is a pivotal facet of end-of-life care for patients. Previous research has revealed substantial global disparities in this issue, with limited investigations conducted in China.
Methods: A retrospective study investigating the prevalence of withholding or withdrawing life-sustaining treatments at an intensive care unit in a tertiary hospital from January 2013 to May 2018 was conducted to elucidate the associated characteristics. The primary outcome measure was the prevalence of withholding or withdrawing life-sustaining treatments. The secondary measures were the demographic and clinical data. Univariate and multivariate logistic regression analyses were performed to determine associations between the clinical characteristics and the decision-making.
Results: This analysis included 437 patients, of which 372 (85.1%) experienced withholding or withdrawal of life-sustaining treatments. Older age (odds ratio [OR]: 1.03; 95% confidence interval [CI]: 1.01-1.05), rural residence (OR: 2.92; 95% CI: 1.17-7.32), belonging to the local province (OR: 1.38; 95% CI: 1.22-1.57), lower per capita income group (OR: 3.59; 95% CI: 2.52-5.09), and a primary diagnosis of trauma (OR: 4.95; 95% CI: 1.19-20.64), neurosurgical disorder (OR: 4.42; 95% CI: 1.76-11.06), or neurological disorder (OR: 12.33; 95% CI: 1.56-97.52) were significantly associated with the decision to withhold or withdraw life-sustaining treatments.
Conclusion: Withholding or withdrawing life-sustaining treatments may vary based on factors such as age, residential location, per capita income, and the primary diagnosis. It is imperative that healthcare policymakers acknowledge these variations and consider the local ethical norms and cultural practices when facing this issue.
Working in prehospital emergency medical services (EMS) can be unpredictable and emotionally demanding for ambulance clinicians (ACs). Burnout, stress, poor sleep quality, fatigue, and psychological health issues increase the risk of accidents and adverse events related to occupational and patient safety. This scoping review aimed to identify and map the existing literature on the current state of the effect of ACs’ well-being on occupational or patient safety risks in prehospital emergency medical services settings. The methodologies of the Joanna Briggs Institute and Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines were used. The databases searched included CINAHL Plus, PubMed, Scopus, Web of Science, and MedNar on March 8, 2024. Peer-reviewed and nonpeer-reviewed scientific and nonscientific sources were searched. The reference lists of the selected sources were screened for further papers. Participants who were ACs working in prehospital EMS and reported their physical, psychological, and social well-being related to adverse events in occupational or patient safety were eligible for inclusion. Quantitative, qualitative, and mixed-method studies; reviews; text, opinion, and discussion papers; and gray literature were included. Two reviewers independently reviewed the titles, abstracts, and full texts and assessed the quality of the sources. Data were extracted from the 2 reviewers by using an extraction tool. Data were analyzed using numerical and thematic methods. In total, 35 sources were included. Four themes were identified from the heterogeneous data: Deficiencies in psychological well-being, Deficiencies in physical well-being, Deficiencies in psychophysical well-being, and Deficiencies in social well-being. Fatigue and stress experienced by ACs are the most important factors that negatively affect patient and occupational safety. Deficiencies in psychophysical well-being have a clear effect on both patient and occupational safety. There is limited evidence on the effect of ACs’ well-being on patient and occupational safety in prehospital EMS.
The 21st-century global health landscape presents unprecedented challenges, such as antimicrobial resistance, mental health issues, and the rapid spread of infectious diseases due to urbanization and mobility. The Sendai Framework and initiatives such as Singapore’s analytics in combating dengue exemplify the push for disaster risk reduction and advanced preparedness. The recent pandemic has underscored the vulnerabilities of health systems, highlighting the need for telehealth and improved emergency response capacities. Military-civilian partnerships and psychological support for healthcare workers have emerged as some critical components. Embracing an all-hazard approach and prioritizing environmental and psychological resilience are key to a robust, culturally sensitive global health strategy, emphasizing the importance of open-access research for comprehensive global preparedness.
Background: Well-designed and functioning emergency medical service (EMS) can provide equitable access to emergency care to improve health issues, especially in low- and middle-income countries where the majority of deaths are due to conditions that could be treated with emergency care. To address this gap, this study explored the contextually appropriate development process in addition to the system architecture, which is lacking in Global South EMS research.
Method: This study was a thematic analysis of the development of EMS systems in six Asian countries. Experts in emergency care were selected through convenience sampling. Each country described and evaluated its EMS system using a standardized form with 102 EMS items that cover the emergency care system in terms of leadership, governance, financing, community-based activities, prehospital care, and quality assessment. From the descriptions, various themes were extracted focusing on the developmental perspective of EMS in Asia.
Result: The study identified the domain of the developmental focus, best practices, and future strategies for EMS in the Asian region. The identified areas for developmental focus are governance, multidisciplinary collaboration, communication/coordination, community participation, decentralization, equitable access, supply-demand balance, and quality assurance activities.
Conclusion: Countries under investigation achieved progress in planning, implementing, and sustaining EMS through varied strategies in the mentioned focal areas that can be emulated by other countries in this region. Further, their development levels varied according to the extent to which each country realized the development principles identified in this study.
Background: We present an atypical case of severe metabolic alkalosis, not reported in the literature to date.
Case Presentation: Owing to concerns of apneas and desaturation, a 75-year-old man presented to the emergency department with significantly deranged physiology: bicarbonate level of 63.6 mmol/L, a base excess of 40.6, and a potassium concentration of 1.9 mmol/L.Primary diagnoses included metabolic alkalosis secondary to fludrocortisone therapy with respiratory compensation, hypokalemia, and hypochloremia. He initially received potassium replacement with cardiac monitoring, followed by permissive hypercapnia in the intensive care unit. He received acetazolamide to further improve his acid-base status. The patient had a good outcome with gradual return of his pH and bicarbonate levels to baseline. He was then discharged.
Conclusion: Iatrogenic mineralocorticoid excess should be considered when the patient presents with significantly raised bicarbonate levels. When starting fludrocortisone, renal function needs to be diligently monitored due to risk of hypokalemia metabolic alkalosis.