Combination of reverse shock index and simplified motor score as a strong discriminator of trauma outcomes

BACKGROUND

The reverse shock index multiplied by simplified motor score (rSI-sMS) is a novel and rapid measure for assessing injury severity in patients with trauma in prehospital settings; however, its discriminant ability requires further validation.

METHODS

A retrospective cohort study was conducted from trauma database of Taipei Tzu Chi Hospital to compare the accuracy of the rSI-sMS with that of the shock index, modified shock index, reverse shock index multiplied by the Glasgow Coma Scale (rSI-GCS), and the reverse shock index multiplied by GCS motor subscale (rSI-GCSM) for discriminating in-hospital mortality, intensive care unit (ICU) admissions, prolonged ICU stays ≥14 days, and prolonged hospital stays ≥30 days in patients with trauma.

RESULTS

A total of 11,760 patients from the trauma database were included. rSI-sMS had significantly better accuracy in discriminating in-hospital mortality, ICU admissions, prolonged ICU stays (≥14 days), and prolonged hospital stays (≥30 days) than the shock index, modified shock index, and rSI-GCSM, whereas its accuracy was similar to that of the rSI-GCS. Furthermore, rSI-sMS had better accuracy for discriminating clinical outcomes in patients with an injury severity score (ISS) ≥16, motor vehicle collisions, falls, no chronic disease, and cardiovascular disease as well as in geriatric and nongeriatric patients. In patients with mixed and isolated brain injuries, rSI-sMS accurately discriminated the four clinical outcomes, similar to rSI-GCS. The optimal cutoff value of rSI-sMS had a discriminant ability of 85.0, 78.6, 75.2, and 81.0% for in-hospital mortality, ICU admissions, ICU stay ≥14 days, and hospital stays of ≥30 days, respectively.

CONCLUSIONS

Compared with the shock index, modified shock index, and rSI-GCSM, rSI-sMS is a more accurate field triage scoring system for discriminating in-hospital mortality, ICU admissions, prolonged ICU stay, and prolonged hospital stays in patients with trauma.

Systematic review and meta-analysis of the treatment of hypernatremia in adult hospitalized patients: impact on mortality, morbidity, and treatment-related side effects

BACKGROUND

Hypernatremia is relatively common in acutely ill patients and associated with mortality. Guidelines recommend a slow rate of correction (≤ 0.5 mmol/L per hour). However, a faster correction rate may be safe and improve outcomes.

OBJECTIVES

To evaluate the impact of sodium correction rates on mortality and hospital length of stay and to assess types of hypernatremia treatment and treatment side effects.

METHODS

We conducted a systematic review and meta-analysis according to PRISMA guidelines, searching Ovid MEDLINE, Embase, and CENTRAL databases from inception to August 2024. Studies reporting sodium correction rates and clinical outcomes in hospitalized adults were included. A random-effects meta-analysis assessed mortality and hospital length of stay, with subgroup analyses exploring correction timing and severity. Treatment method and side effects were analyzed qualitatively.

RESULTS

We reviewed 4445 articles and included 12 studies. Faster correction rates (> 0.5 mmol/L/h) overall showed no significant change in mortality and a high level of heterogeneity (OR 0.68, 95 % CI: 0.38-1.24, I2 = 95 %). However, subgroup analyses found significantly lower mortality with faster correction of hypernatremia at the time of hospital admission (OR 0.48, 95 % CI: 0.35-0.68, I2 = 2 %), with fast correction within the first 24 h of diagnosis (OR 0.48, 95 % CI: 0.31-0.73, I2 = 65 %), and for severe hypernatremia (OR 0.55, 95 % CI: 0.33-0.92, I2 = 79 %). There was no significant different in hospital length of stay by correction rate. No major neurological complications were reported when the correction rate was < 1 mmol/L/h.

CONCLUSION

Faster sodium correction appears safe and may benefit patients with severe admission-related hypernatremia, particularly within the first 24 h. Further studies are needed to refine correction protocols.

Nano-adjuvant based on lipo-imiquimod self-assembly for enhanced foot-and-mouth disease virus vaccine immune responses via intradermal immunization

Excellent adjuvants and proper immunization routes play pivotal roles in activating a robust immune response. Nano-adjuvants have the advantages of enhancing immunogenicity, targeting delivery, and improving stability to provide a new solution for vaccine delivery. In this work, we designed and synthesized a pro-immunostimulant of liposolubility imiquimod derivative IMQP, which was synthesized by reaction of palmitoyl chloride with parent imiquimod (IMQ). Using an inactivated foot-and-mouth disease virus (FMDV) as antigen, and the as-synthesized IMQP containing long carbon chain as nano-adjuvant, we formulated a self-assembled foot-and-mouth disease nano-vaccine (IMQP@FMDV) by re-precipitation method for intradermal (I.D.) immunity vaccination. Because of its small size (∼131.75 ± 41.70 nm) and fat-soluble, the as-fabricated lipid nanoparticles (LNPs) showed promising potential for efficient delivery of antigens to immune cells. Also, lysosomal escape was confirmed by co-localization dendritic cells (DCs). Our findings demonstrated that IMQP nano-adjuvant greatly promoted the expression and secretion of cytokines and chemokines with a balance Th1/Th2 immune response via the I.D. administration. Meanwhile, due to the slowly releasing of IMQ by the hydrolysis of IMQP, IMQP persistently stimulated antigen-presenting cells (APCs) maturation and promoted antigen presentation, and subsequently induced the activation of the related downstream NF-кB and MAPK pathways of the TLR7 signaling pathway, thereby stimulated a robust both humoral and cellular immune response.

Novel Strategies to Promote Intensive Care Unit Recovery via Personalized Exercise, Nutrition, and Anabolic Interventions

Survivors of critical illness experience significant morbidity, reduced physiologic reserve, and long-term complications that negatively impact quality of life. Although rehabilitative treatments are beneficial during early recovery, there is limited evidence regarding effective multimodal rehabilitation, nutrition, and anabolic nutrient/agent strategies for improving long-term outcomes. This review discusses novel personalized rehabilitation, nutrition, and anabolic nutrient/agent (ie, creatine, β-hydroxy-β-methylbutyrate, testosterone) approaches that allow for precise exercise and nutrition prescription and have potential to improve patient care, address continued medical needs, and optimize long-term recovery. Continued research is needed to further evaluate effectiveness and implementation of these strategies throughout the continuum of care.

Clinical assessment of computed tomography for detecting ingested blister packs: A single-center retrospective study

Objectives

Blister pack (BP) ingestion poses serious risks, such as gastrointestinal perforation, and accurate localization by computed tomography (CT) is a common practice. However, while it has been reported in vitro that CT visibility varies with the material type of BPs, there have been no reports on this variability in clinical settings. In this study, we investigated the CT detection rates of different BPs in clinical settings.

Methods

This single-center retrospective study from 2010 to 2022 included patients who underwent endoscopic foreign body removal for BP ingestion. The patients were categorized into two groups for BP components, the polypropylene (PP) and the polyvinyl chloride (PVC)/polyvinylidene chloride (PVDC) groups. The primary outcome was the comparison of CT detection rates between the groups. We also evaluated whether the BPs contained tablets and analyzed their locations.

Results

This study included 61 patients (15 in the PP group and 46 in the PVC/PVDC group). Detection rates were 97.8% for the PVC/PVDC group compared to 53.3% for the PP group, a significant difference (p < 0.01). No cases of BPs composed solely of PP were detected by CT. Blister packs were most commonly found in the upper thoracic esophagus.

Conclusions

Even in a clinical setting, the detection rates of PVC and PVDC were higher than that of PP alone. Identifying PP without tablets has proven challenging in clinical. Considering the risk of perforation, these findings suggest that esophagogastroduodenoscopy may be necessary, even if CT detection is negative.

Artificial Intelligence in Emergency Medicine: A Primer for the Nonexpert

Artificial intelligence (AI) is increasingly being utilized to augment the practice of emergency medicine due to rapid technological advances and breakthroughs. AI applications have been used to enhance triage systems, predict disease-specific risk, estimate staffing needs, forecast patient decompensation, and interpret imaging findings in the emergency department setting. This article aims to help readers without formal training become informed end-users of AI in emergency medicine. The authors will briefly discuss the principles and key terminology of AI, the reasons for its rising popularity, its potential applications in the emergency department setting, and its limitations. Additionally, resources for further self-studying will also be provided.

A comparative analysis of trauma-related mortality in South Korea using classification models

BACKGROUND

Reducing mortality among severe trauma patients requires the establishment of an effective emergency transportation system and the rapid transfer of patients to appropriate medical facilities. Machine learning offers significant potential to enhance the efficiency and quality of these emergency medical services.

METHODS

A retrospective secondary analysis was conducted using region-specific trauma survey data. The analysis focused on socio-economic characteristics, mechanisms of injury, injury severity, and variables indicating the effectiveness of the emergency medical system in optimizing machine learning algorithms for predicting severe patient transportation decisions.

RESULTS

Among the 8,769 patients with severe trauma, 7.2 % died in the hospital, with an average age of 50.06 years. The average injury severity score was 8.44, and the average time from accident reporting to arrival at the emergency medical facility was 55.39 min. The trend showed that as the level of the emergency medical institution increased, the patient transport time increased, while the mortality rate decreased. Additionally, XGBoost showed the best performance in mortality classification using a dataset sampled with SMOTE-ENN. Although the difference was minimal, undersampling slightly outperformed oversampling in the classification of emergency patients.

CONCLUSION

The treatment of emergency patients is influenced not only by transport time but also by the resources and staff levels of specialized emergency medical centers, which in turn affect survival rates. Furthermore, given the superior performance of composite sampling methods in analyzing imbalanced datasets, the importance of considering such imbalanced datasets in the analysis is evident.

Utilization and outcomes of nonintubated extracorporeal membrane oxygenation as a bridge to lung transplant

BACKGROUND

Nonintubated extracorporeal membrane oxygenation (ECMO) has been increasingly utilized for patients with severe respiratory failure. Since data on its use as a bridge to lung transplant remain limited, we evaluated its use in a national cohort.

METHODS

Adult lung-only transplant recipients bridged with ECMO May 4, 2005 to March 8, 2023 in the United Network for Organ Sharing database were categorized by use of ECMO and mechanical ventilation (MV) at transplant (ECMO+MV vs ECMO-only). We compared post-transplant intubation and ECMO at 72 hours, length of stay, and survival.

RESULTS

The 1,599 transplants identified included 902 (56.4%) bridged with ECMO+MV and 697 (43.6%) bridged with ECMO-only. ECMO-only recipients had higher median age (52 vs 49 years, p < 0.001), shorter ischemic times (5.7 vs 6.0 hours, p = 0.003), and similar lung allocation scores (89.5 vs 89.6, p = 0.11). ECMO-only recipients had lower likelihood of intubation at 72 hours (56.5% vs 77.5%; adjusted odds ratio 0.33 [95% confidence interval (CI): 0.25, 0.42], p < 0.001) and shorter lengths of stay (28 vs 35 days; coefficient -0.19 [95% CI: -0.27, -0.11], p < 0.001). ECMO-only recipients had higher 90-day survival (92.1% vs 89.1%; adjusted hazards ratio (aHR) 0.69 [95% CI: 0.48, 0.99], p = 0.04) but similar 1-year (83.1% vs 81.5%; aHR 0.87 [95% CI: 0.67, 1.12], p = 0.27) and 5-year (54.6% vs 54.7%; aHR 0.98 [95% CI: 0.82, 1.17], p = 0.83) survival.

CONCLUSIONS

Nonintubated ECMO bridge to lung transplant was associated with improved perioperative outcomes and short-term survival and should be considered for candidates requiring ECMO.

The impact of extreme temperatures on emergency department visits: A systematic review of heatwaves, cold waves, and daily temperature variations

Extreme temperature events increasingly challenge global public health systems, affecting both emergency department (ED) presentations and subsequent hospital admissions. Understanding these impacts on emergency healthcare utilization is critical for effective resource planning and public health preparedness. This systematic literature review, conducted following PRISMA guidelines, examines the influence of extreme temperature events on ED admissions. A comprehensive database search from 2012 to 2024 identified 42 relevant studies and two of them considered both heatwaves, coldwaves or temperature variation: 22 on heatwaves, 6 on cold waves, and 16 on temperature variations. Heatwaves are consistently associated with increased ED admissions for various health conditions, including orthopaedic trauma and exacerbations of chronic illnesses. At the same time, cold waves are linked primarily to respiratory and cardiovascular issues, often with delayed effects. Several studies indicate that older adults, those with pre-existing conditions, and socioeconomically disadvantaged populations may face disproportionately severe consequences during these events. Socio-demographic factors, including age, gender, socioeconomic status, and geographic location, significantly influence these outcomes. These findings highlight the differential impacts of extreme temperature events on ED utilization, emphasizing the importance of preparing EDs for post-event surges and advocating for coordinated emergency planning and targeted public health interventions to manage these challenges effectively. IMPLICATIONS FOR PUBLIC HEALTH: The findings of this study provide actionable insights for clinicians, academics, and policymakers to understand better the impact of extreme temperature events on emergency departments. This knowledge can guide the development of targeted public health strategies, enhance resource allocation, and strengthen healthcare systems to improve outcomes for vulnerable populations.

Platelet flux in trauma-associated venous thromboembolism: A secondary analysis of the Consortium of Leaders in the Study of Traumatic Thromboembolism (CLOTT) studies

BACKGROUND

Venous thromboembolism (VTE) after traumatic injury is morbid. Evaluating changes in platelets in injured patients who develop VTE could identify platelet-based strategies for management of thrombotic complications after injury.

METHODS

In a prospectively designed secondary analysis of a multicenter cohort study conducted by the Consortium of Leaders in the Study of Traumatic Thromboembolism (CLOTT1) study group, injured patients aged 18 to 40 years admitted for a minimum of 48 hours with at least one risk factor for VTE were evaluated. A subset of CLOTT1 patients had platelet aggregometry and thromboelastography performed to examine platelet function (CLOTT2). Patients who developed VTE were compared with those who did not.

RESULTS

Of 7,805 patients from CLOTT1 (mean [SD] age, 29.1 [6.4] years; 1,987 [25.5%] female), 425 (5.4%) developed VTE. Platelet count was lower at each time point for patients with VTE (admission: 242 [234-251] vs. 254 [252-256], p < 0.01; hospital day 1: 157 [150-164] vs. 197 [195-198], p < 0.01; all counts ×109/L). An initial 10-point reduction in platelet count was associated with development of VTE (odds ratio, 1.32 [1.13-1.53]; p < 0.01) controlling for shock, injury severity, coagulopathy, sex, and product transfusion. When evaluating 129 CLOTT2 patients, velocity of platelet aggregation was higher on admission in the VTE group (18.5 vs. 12.8 aggregation units/min; p < 0.01) in response to adenosine diphosphate stimulation. In response to thrombin stimulation, velocity of platelet aggregation was higher at 48 hours (34.4 vs. 12.3 aggregation units/min; p < 0.01), and overall aggregation was higher in the VTE group at 72 hours (area under the curve, 173.2 vs. 129.6; p < 0.01). Thromboelastography results were not different between groups.

CONCLUSION

This study identified an association of early reduction in platelet count with the development of VTE in injured patients at risk for VTE. P2Y1/2 and protease-activated receptor 1 receptor stimulation changes in platelet aggregation responses are altered in VTE patients. Interrogating platelet count and functional responses may be beneficial in evaluating thrombotic complications after injury.

LEVEL OF EVIDENCE

Diagnostic Test/Criteria; Level II.

Predicting postoperative pulmonary infection in elderly patients undergoing major surgery: a study based on logistic regression and machine learning models

BACKGROUND

Postoperative pulmonary infection (POI) is strongly associated with a poor prognosis and has a high incidence in elderly patients undergoing major surgery. Machine learning (ML) algorithms are increasingly being used in medicine, but the predictive role of logistic regression (LR) and ML algorithms for POI in high-risk populations remains unclear.

METHODS

We conducted a retrospective cohort study of older adults undergoing major surgery over a period of six years. The included patients were randomly divided into training and validation sets at a ratio of 7:3. The features selected by the least absolute shrinkage and selection operator regression algorithm were used as the input variables of the ML and LR models. The random forest of multiple interpretable methods was used to interpret the ML models.

RESULTS

Of the 9481 older adults in our study, 951 developed POI. Among the different algorithms, LR performed the best with an AUC of 0.80, whereas the decision tree performed the worst with an AUC of 0.75. Furthermore, the LR model outperformed the other ML models in terms of accuracy (88.22%), specificity (90.29%), precision (44.42%), and F1 score (54.25%). Despite employing four interpretable methods for RF analysis, there existed a certain degree of inconsistency in the results. Finally, to facilitate clinical application, we established a web-friendly version of the nomogram based on the LR algorithm; In addition, patients were divided into three significantly distinct risk intervals in predicting POI.

CONCLUSIONS

Compared with popular ML algorithms, LR was more effective at predicting POI in older patients undergoing major surgery. The constructed nomogram could identify high-risk elderly patients and facilitate perioperative management planning.

TRIAL REGISTRATION

The study was retrospectively registered (NCT06491459).

The Challenges of an Emergency Nurse Team Working in an Active Conflict Area

OBJECTIVE

Nurses, as the largest group of frontline responders, play a crucial role in managing catastrophic incidents and addressing the health needs of affected populations. This study aims to identify and analyze the challenges faced by emergency nurses in Palestine who work in active conflict zones.

METHODS

A quantitative, descriptive study design was employed. The research was conducted across emergency departments in 7 hospitals located in the West Bank. Data were collected from 171 nurses using a sociodemographic questionnaire and a challenge-specific questionnaire, developed and validated through literature review and expert consultations.

RESULTS

The study revealed that 70% of the nurses were aged between 25-29 years, with 51% being male and 60% married. Most respondents (95%) held a bachelor's degree, 72% had received advanced cardiac life support (ACLS) training, and 68% had advanced trauma life support (ATLS) training. Additionally, 76% of the nurses were informed about critical cases before the patients arrived at the hospital. The main challenge during emergencies, as the results mention, are inadequate numbers of nurses and physicians (60%). There was a significant concern regarding whether the number of nurses was sufficient to manage the demands and pressures specific to active conflict environments, with 62% of those in nursing feeling unsafe.

CONCLUSIONS

The scope of emergency nurses' challenges in managing several hospitals in areas of armed conflict was examined in this study. The resulting overview of their duties, difficulties, and experiences serves as a useful tool and presents crucial details for future emergency nursing workforce readiness. To perform effectively in armed conflict situations, emergency nurses complete a variety of preparatory courses; however, the necessary education and training should be carefully designed in accordance with their actual roles and responsibilities in these circumstances.

Gut integrity in intensive care: alterations in host permeability and the microbiome as potential therapeutic targets

BACKGROUND

The gut has long been hypothesized to be the "motor" of critical illness, propagating inflammation and playing a key role in multiple organ dysfunction. However, the exact mechanisms through which impaired gut integrity potentially contribute to worsened clinical outcome remain to be elucidated. Critical elements of gut dysregulation including intestinal hyperpermeability and a perturbed microbiome are now recognized as potential therapeutic targets in critical care.

MAIN BODY

The gut is a finely tuned ecosystem comprising ~ 40 trillion microorganisms, a single cell layer intestinal epithelia that separates the host from the microbiome and its products, and the mucosal immune system that actively communicates in a bidirectional manner. Under basal conditions, these elements cooperate to maintain a finely balanced homeostasis benefitting both the host and its internal microbial community. Tight junctions between adjacent epithelial cells selectively transport essential molecules while preventing translocation of pathogens. However, critical illness disrupts gut barrier function leading to increased gut permeability, epithelial apoptosis, and immune activation. This disruption is further exacerbated by a shift in the microbiome toward a "pathobiome" dominated by pathogenic microbes with increased expression of virulence factors, which intensifies systemic inflammation and accelerates organ dysfunction. Research has highlighted several potential therapeutic targets to restore gut integrity in the host, including the regulation of epithelial cell function, modulation of tight junction proteins, and inhibition of epithelial apoptosis. Additionally, microbiome-targeted therapies, such as prebiotics, probiotics, fecal microbiota transplantation, and selective decontamination of the digestive tract have also been extensively investigated to promote restoration of gut homeostasis in critically ill patients. Future research is needed to validate the potential efficacy of these interventions in clinical settings and to determine if the gut can be targeted in an individualized fashion.

CONCLUSION

Increased gut permeability and a disrupted microbiome are common in critical illness, potentially driving dysregulated systemic inflammation and organ dysfunction. Therapeutic strategies to modulate gut permeability and restore the composition of microbiome hold promise as novel treatments for critically ill patients.

Optimization and advances in negative pressure wound therapy for the management of necrotizing fasciitis in the upper limb

Necrotizing fasciitis (NF) is a rapidly progressing, life-threatening soft tissue infection, with upper limb NF posing a particularly serious threat to patient survival and quality of life. Negative pressure wound therapy (NPWT) has shown considerable advantages in accelerating wound healing and mitigating functional impairment. A retrospective study by Lipatov et al. demonstrated that NPWT significantly reduced the time needed for wound closure preparation while enhancing the success rate of local repair. Despite its benefits, certain limitations highlight the need for further optimization. This paper investigates the potential for personalized dynamic regulation of NPWT, its integration with adjunctive therapies, and the role of multidisciplinary collaboration. Furthermore, it explores the incorporation of advanced technologies such as artificial intelligence, imaging modalities, and biomaterials, presenting novel pathways for the personalized management and global standardization of NF treatment.

[Challenges and perspectives of family support in the intensive care unit: focus on vulnerable relatives]

BACKGROUND

Supporting relatives in the intensive care unit (ICU) is a complex task, especially when it comes to vulnerable people such as children, very old persons or socioeconomically disadvantaged persons. They are exposed to particular physical and psychological stress and require targeted awareness from healthcare professionals.

OBJECTIVE

What person-centered challenges and support services are available for vulnerable relatives in the ICU?

RESULTS

This article highlights the various challenges and support services for vulnerable relatives in ICUs. Depending on the group and individual, there are a variety of challenges such as a lack of helpful coping strategies, difficult access to adequate information, communication problems and a generally increased risk of persistent long-term consequences. Targeted training of specialist staff, specific practical instructions, culturally sensitive communication strategies and the use of supporting resources even digital ones can enable person-centered and vulnerability-reducing support.

CONCLUSION

A high level of interprofessional and intercultural competence and the development of specific support services can relieve the burden on both relatives and specialist staff and contribute to improving the quality of care.

Traumatic vertebral artery occlusion is associated with high rates of recanalization: insights from a systematic review and meta-analysis

BACKGROUND

Vertebral artery occlusion (VAO) is a known complication of blunt cervical injuries and can be associated with a risk of devastating strokes. VAO can spontaneously recanalize, particularly following cervical spine intervention. The aim of this study is to examine overall recanalization rates, recanalization in the context of cervical spine intervention, and the associations between VAO and stroke, spinal cord injury, and acute cervical deformity.

METHODS

We conducted a systematic review and meta-analysis of literature using Medline, EMBASE, Cochrane, and manual citation searches. Included studies reported at least 5 adult patients with traumatic VAO and delayed radiographic outcomes, unless embolization was performed for permanent occlusion during the initial admission. Cervical spine intervention was defined as open surgery or external traction. Random effects meta-analysis was used.

RESULTS

Fifteen of 755 studies were included. VAO was associated with spinal cord injury in 67% of cases (95%CI, 43-92%, n = 132, p < 0.001) and acute cervical deformity in 73% (95%CI, 62-83%, n = 91, p < 0.001). The incidence of stroke at presentation was 13% (95%CI, 6-19%, n = 269, p < 0.001). The overall rate of VAO recanalization was 36% in non-embolized patients (95%CI, 23-48%, n = 285, p < 0.001). When only studies reporting on cervical spine intervention were considered, the rate of recanalization post-intervention was 57% (95%CI, 30-85%, n = 45, p < 0.001). Follow-up periods were highly variable, ranging from 1 to 103 weeks.

CONCLUSIONS

A substantial portion of traumatic VAOs recanalized at follow-up, with more than half of patients undergoing cervical spine intervention recanalizing. The analyses revealed considerable heterogeneity, likely indicative of variability in clinical practices, established guidelines and reporting standards. These findings offer important insights into the natural history of traumatic VAO and should be considered when choosing management strategies for this patient population.

Prevalence and variability in use of physical restraints in intensive care units: A systematic review and meta-analysis

BACKGROUND

Given the varying perspectives on the use of physical restraint (PR) over the past decades and the provided protocols to minimise its occurrence in intensive care units (ICUs), a comprehensive study was deemed necessary to examine the prevalence and variation of PR use in ICUs.

OBJECTIVE

The aim of this study was to estimate the overall proportions of PR utilised in adult ICUs whilst examining the various factors contributing to the variability of these estimates.

METHODS

A search of five databases (PubMed, Cochrane Library, Scopus, Embase, and Web of Science) was performed. Studies published in English and available online from inception to December 18, 2024, were included. A pooled estimate with a 95% confidence interval was calculated, and the data were represented by the random-effect model. Analysis was performed using the STATA statistical software (version 17).

RESULTS

The meta-analysis included 39 studies, with a sample size of 21 665 patients. The overall prevalence of patients exposed to PRs was 41.6% (95% confidence interval: 33.8%-49.5%). The heterogeneity was significantly high (I2 = 99.61%), and the Q Cochrane test for homogeneity was significant (p value < 0.001), indicating substantial variability between studies. Subgroup analysis regarding the continent and restraint method contributed to a lowered heterogeneity.

CONCLUSIONS

There was considerable variation in reported estimates of PR prevalence in adult ICUs. Despite valid guidelines and recommendations supporting the reduction of PR, the results of our study show its significant prevalence. Additionally, our study demonstrated a relationship between PR use and delirium, sedation use, and mechanical ventilation. This study emphasises the importance of managing and focussing on PRs in ICUs. Also, it is crucial to evaluate barriers to guideline implementation.

REGISTRATION

The systematic review protocol has been prospectively registered in the International Prospective Register of Systematic Reviews: CRD42024566480.

Comprehensive management evaluation of anaphylactic shock in dental clinics across developing countries

Anaphylaxis shock is defined as a sudden, severe allergic reaction that can be life-threatening and typically occurs within minutes to a few hours following exposure to a triggering substance. While anaphylaxis shock can be a rare side effect of dental treatments, including sedation and anesthesia, dentists must be prepared to respond promptly and appropriately to prevent complications such as airway obstruction and cardiac issues. In developing countries, managing anaphylactic shock presents challenges, often due to low awareness among dentists and a lack of necessary equipment. Immediate diagnosis and management are crucial in a dental setting when anaphylaxis shock occurs. Therefore, dental practitioners must be trained to diagnose and manage such situations effectively. A lack of comprehensive understanding of allergy testing, diagnosis, and management can have serious consequences.

Update on Neuroprotection after Traumatic Brain Injury

Traumatic brain injury (TBI) is a prevalent cause of morbidity and mortality worldwide. A focus on neuroprotective agents to prevent the secondary injury cascade that follows moderate-to-severe TBI has informed the field greatly but has not yielded any viable therapeutic options to date. New strategies and pharmacotherapy options for neuroprotection continue to be evaluated, including tranexamic acid, progesterone, cerebrolysin, cyclosporin A, citicholine, memantine, and lactate. Biomarkers of injury that can aid in diagnosis and prognosis have also been elucidated and are incrementally being used in clinical practice. The spectrum of TBI severity has also gained increasing attention as it relates to mild TBI or concussion, blast injury, and subacute or chronic subdural hematomas. In this review, we review the pathophysiology, recent clinical trials, and future directions for acute TBI.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2024

The 2024 revised edition of the Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock (J-SSCG 2024) is published by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine. This is the fourth revision since the first edition was published in 2012. The purpose of the guidelines is to assist healthcare providers in making appropriate decisions in the treatment of sepsis and septic shock, leading to improved patient outcomes. We aimed to create guidelines that are easy to understand and use for physicians who recognize sepsis and provide initial management, specialized physicians who take over the treatment, and multidisciplinary healthcare providers, including nurses, physical therapists, clinical engineers, and pharmacists. The J-SSCG 2024 covers the following nine areas: diagnosis of sepsis and source control, antimicrobial therapy, initial resuscitation, blood purification, disseminated intravascular coagulation, adjunctive therapy, post-intensive care syndrome, patient and family care, and pediatrics. In these areas, we extracted 78 important clinical issues. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members. As a result, 42 GRADE-based recommendations, 7 good practice statements, and 22 information-to-background questions were created as responses to clinical questions. We also described 12 future research questions.

What challenges of family-clinician conversations in the intensive care unit can teach us: A cross-sectional survey study

OBJECTIVES

To explore the perspectives of intensive care unit personnel and patients' family members on challenges of family-clinician conversations and corresponding learning needs.

RESEARCH METHODOLOGY/DESIGN

Cross-sectional survey study.

SETTING

Two medical intensive care units of a German academic tertiary care hospital.

MAIN OUTCOME MEASURES

Data were collected using an investigator-designed online survey with open- and closed-ended questions. Descriptive statistics were conducted to determine frequencies, free-text responses were analysed using directed qualitative content analysis.

FINDINGS

The responses of 94 family members, 42 nurses, and 28 physicians were analysed (response rate: 45%). Regarding the clinicians' perspective, three main themes of challenges were deduced: ICU setting, Staff-related challenges, and Family-related challenges. Conversely, the majority of participating family members reported challenges both cognitive and affective in nature, e.g., remembering provided information or discussing the patient's prognosis. Most clinicians stated their need for a corresponding communication skills training to successfully navigate those challenges in clinical practice, particularly regarding conveying complex information, handling strong emotions, and managing family-clinician conflicts.

CONCLUSION

The identified communication challenges underline the issues of family-clinician conversations that require improvement, making it possible to determine corresponding strategies to attain the desired outcome. Further research is needed to elicit best-practices of communication skills trainings for family-clinician conversations and its implementation in critical care settings.

IMPLICATIONS FOR CLINICAL PRACTICE

These findings invite clinicians to engage in self-reflection to identify individually perceived communication challenges and learning needs. Faculty and healthcare institutions may further use these findings to conceptualise tailored communication skills trainings to contribute to the advancement in nursing and medical education.

Indications for extracorporeal membrane oxygenation in older adult patients with accidental hypothermia and hemodynamic instability

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) indications in patients with accidental hypothermia (AH) and hemodynamic instability before cardiac arrest (CA) are unclear. We aimed to identify a subgroup of these patients who would benefit from ECMO rewarming.

METHODS

This study was a post-hoc analysis of the ICE-CRASH study (2019-2022), a prospective, multicenter, observational study throughout Japan. Among the 499 patients (core temperature < 32 °C, age > 18 years), 175 with AH and hemodynamic instability were selected. The primary outcome was 28-day mortality. We examined the effect of ECMO on 28-day mortality after risk stratification based on age, activities of daily living (ADLs), core temperature, Glasgow coma scale (GCS) score, systolic blood pressure (SBP), arrhythmia, pH, and lactate levels. The secondary outcomes were rewarming rate, event-free days (ICU-, ventilator-, and catecholamine-free days), and complications.

RESULTS

The patients were divided into ECMO (N = 17) and non-ECMO (N = 158) groups. No significant difference was observed in the 28-day survival rates between the ECMO (13/17, 77%) and non-ECMO (120/158, 76%) groups (p = 0.96). The restricted cubic spline curve showed that the 28-day mortality increased with a GCS score ≤ 8; no relationship was observed between 28-day mortality and decreased SBP or core temperature. No significant difference was observed in the effectiveness of ECMO based on age (< 80 vs. ≥ 80 years), ADLs (independent vs. assistance needed/unknown), core temperature (≥ 26 vs. < 26 °C), GCS (> 8 vs. ≤ 8), SBP (≥ 60 vs. < 60 mmHg), arrhythmia (sinus rhythm vs. arrhythmia), pH (≥ 7.1 vs. < 7.1), and serum lactate level (< 3.0 vs. ≥ 3.0 mmol/L). The rewarming rate was significantly higher in the ECMO group than in the non-ECMO group (2.5 °C/h vs. 1.3 °C/h, p < 0.001), and ICU-, ventilator-, and catecholamine-free days were significantly higher in the non-ECMO group than in the ECMO group. Bleeding complications were significantly more common in the ECMO group than in the non-ECMO group (77% vs. 26%, p < 0.001).

CONCLUSIONS

We were unable to identify a subgroup of older adult patients with AH and hemodynamic instability who would benefit from ECMO. The ICE-CRASH study was registered with the University Hospital Medical Information Network Clinical Trial Registry on April 1, 2019 (UMIN-CTR ID: UMIN000036132).

Development and validation of machine learning-based prediction model for outcome of cardiac arrest in intensive care units

Cardiac arrest (CA) poses a significant global health challenge and often results in poor prognosis. We developed an interpretable and applicable machine learning (ML) model for predicting in-hospital mortality of CA patients who survived more than 72 h. A total of 721 patients were extracted from the Medical Information Mart for Intensive Care IV database, divided into the training set (n = 576) and the internal validation set (n = 145). The external validation set containing 856 cases were collected from four tertiary hospitals in Zhejiang Province. The primary outcome was in-hospital mortality. Eleven ML algorithms were utilized to establish prediction models based on data from 72 h after return of spontaneous circulation (ROSC). The results indicate that the CatBoost model exhibited the best performance at 72 h. Eleven variables were ultimately selected as key features by recursive feature elimination (RFE) to construct a compact model. The final model achieved the highest AUC of 0.86 (0.80, 0.92) in the internal validation and 0.76 (0.73, 0.79) in the external validation. SHAP summary plots and force plots visually explained the predicted outcomes. In conclusion, 72-h CatBoost showed promising performance in predicting in-hospital mortality of CA patients who survived more than 72 h. The model still requires further optimization and improvement.

Response on Rapid Review to Inform Policy Guidance on Welsh Respiratory ECMO Provision

Internationally, extracorporeal membrane oxygenation (ECMO) is now a core and standard organ support tool to provide tertiary critical care and cardiac services within a network of hospitals and a key tool for running an effective and efficient cardio-respiratory pathways. The letter aims to put the spotlight on some of the missing clinical evidence on respiratory ECMO and including them will help to arrive at a better-informed national ECMO policy decision.

Gut-Brain Axis-Based Polygala Tenuifolia and Magnolia Officinalis Improve D-gal-Induced Cognitive Impairment in Mice Through cAMP and NF-κB Signaling Pathways

Purpose

Polygala tenuifolia Willd. (PT) is commonly used to address cognitive impairment (CI), while Magnolia officinalis Rehd. et Wils (MO) is often prescribed for gastrointestinal issues as well as CI. This study seeks to explore the impacts and mechanisms behind the combined therapy of PT and MO (PM) in treating CI, based on the concept of the gut-brain axis.

Methods

The characteristic components of PT, MO, and PM were identified using ultra-high performance liquid chromatography-tandem triple quadrupole mass Spectrometry (UPLC-MS/MS). A mouse model was established by D-gal induction, and the effects of PT, MO, and PM on CI were evaluated through behavioral tests, pathological staining, and Enzyme-Linked Immunosorbent Assay (ELISA). Subsequently, network pharmacology was used to analyze the potential mechanisms by which PM improves CI, followed by validation through Western blotting (WB), traditional Chinese medicine (TEM), Immunofluorescence (IF), and 16S rRNA.

Results

PT, MO, and PM can each alleviate cognitive decline and neuropathological damage in D-gal mice to varying degrees, reduce the expression of pro-inflammatory factors (TNF-α, IL-1β, IL-6, IFN-γ, LPS) in serum or hippocampal tissue, and increase SOD and GSH levels. Network pharmacology analysis and molecular experiments confirmed that PM upregulates the expression of tight junction s (TJs), enhances the expression of proteins in the cAMP pathway, and inhibits p-NF-κB-p65 expression. PM reverses D-gal-induced gut microbiota dysbiosis, increases the abundance of SCFA-producing bacteria, and decreases the abundance of LPS-producing bacteria.

Conclusion

PM alleviates CI by reducing inflammation and oxidative stress, protecting the blood-brain barrier (BBB) and intestinal barrier, inhibiting the NF-κB pathway, activating the cAMP pathway, and regulating gut microbiota.

Out-of-hospital care of postpartum hemorrhage: a scoping review

OBJECTIVE

Given the paucity of information on managing out-of-hospital postpartum hemorrhage, this scoping review aimed to systematically map current literature on the scope, depth, and key concepts on the topic, as well as identify gaps and areas for further study.

INTRODUCTION

Postpartum hemorrhage is characterized by blood loss after childbirth that endangers hemodynamic stability of the mother. It can cause rapid deterioration if not managed promptly and remains the leading cause of maternal morbidity and mortality worldwide, particularly in resource-limited, out-of-hospital settings; however, knowledge about its management is limited.

METHODS

The JBI scoping review methodology was utilized for this review. A comprehensive search strategy was employed across MEDLINE (Ovid), CINAHL Complete (EBSCOhost), Embase (Ovid), Scopus, Web of Science, as well as gray literature databases ProQuest Dissertations and Theses and EBSCOhost Open Dissertations. A Google search and a hand-search of relevant, peer-reviewed journals was also performed. Inclusion criteria were applied to identify appropriate literature. Studies that describe emergency out-of-hospital care of both primary and secondary postpartum hemorrhage in women regardless of age, ethnicity, parity, or comorbidities were considered. Of these, only those published in English after 1988 were included. Selection of sources for inclusion were then determined by 2 independent reviewers; discrepancies in outcomes were discussed with a third reviewer. The reference lists of all included sources were screened and authors were contacted before data were extracted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) reporting guideline.

RESULTS

The search yielded 311 unique records, of which 43 were included in the synthesis. All the included studies were published literature, of which, the majority were primary studies and secondary reviews. A significant proportion of the included studies were published by authors from the United States, United Kingdom and Australia. Across the literature, care of patients with OOHBs is hinged on actively managing the third stage, involving pharmacological and mechanical measures to facilitate placenta delivery. When postpartum bleeding compromises hemodynamic stability of the mother, current practices include standard hemorrhage protocols alongside measures to reverse the cause of the hemorrhage. However, our findings indicate substantial inconsistencies in recognition and management of out-of-hospital postpartum hemorrhage. This can be attributed to variabilities in identification methods and interventions, gaps in practitioner knowledge and skillsets, lack of clinical practice guidelines, social determinants affecting health care access, and logistical challenges in providing timely medical support. Such variabilities pose detrimental effects on maternal health and outcomes.

CONCLUSIONS

Current evidence on care of out-of-hospital postpartum hemorrhage is largely made up of published studies representative of countries with diverse economic standards. The concept of actively managing the third stage appears to be increasingly recognized and implemented; however, it remains apparent that out-of-hospital care of postpartum hemorrhage is not well-established, creating room for complications. To improve standardization in clinical practice, further research to establish best practices, customized to environmental and resource availabilities, is warranted. Further investigation on practitioner training and education would also be valuable in ensuring qualified workforce.

REVIEW REGISTRATION

Open Science Framework https://osf.io/dmjcg.

Pediatric Resuscitative Thoracotomy in Infants, Children, and Early Adolescents: A Scoping Review

INTRODUCTION

Recent publications sought to define the role of resuscitative thoracotomy (RT) in the pediatric population; however, few studies guide its use in young children and infants. This review characterizes the presentation and outcomes of patients ≤15 y old undergoing RT.

METHODS

A scoping review querying publications in PubMed, Embase, and Scopus prior to March 2024 was conducted using Covidence software. Eligible articles reported outcomes of patients aged ≤15 y old receiving RT for traumatic injury. The exclusion criteria included non-English, data in aggregate with patients >15 y old or lack of outcomes. Eligible articles underwent data extraction for mechanism of injury, hospital presentation, procedure details, and survival.

RESULTS

The search imported 1550 articles, 294 underwent full-text review, and 26 were included. Notably, 85 articles were excluded for failing to separate pediatric and adult outcomes. Reviewed literature reported on 459 pediatric patients, of which 81 survived (17.6%). Age reporting varied as follows: 10 articles reported the exact age, 5 reported age buckets, and 11 reported an age range only. Of the survivors with known ages, three were <1 y old, seven were 1-4 y old, ten were 5-9 y old, and 39 were 10-15 y old.

CONCLUSIONS

The utility and indications for pediatric RT are understudied in the youngest children. Current literature is limited by inconsistent reporting and poor data granularity. Establishing universal reporting guidelines for pediatric RT will help build complete, uniform databases. A preliminary reporting checklist is proposed to improve data sharing in pediatric RT literature, serving as a first step toward developing evidence-based protocols for young children and infants undergoing RT.

Postoperative adhesions are abrogated by a sustained-release anti-JUN therapeutic in preclinical models

Postoperative abdominal adhesions are the leading cause of bowel obstruction and a cause of chronic pain and infertility. Adhesion formation occurs after 50 to 90% of abdominal operations and has no proven preventative or treatment strategy. Abdominal adhesions derive primarily from the visceral peritoneum and are composed of polyclonally proliferating tissue-resident fibroblasts. We have previously shown that signaling of the transcription factor JUN regulates adhesiogenesis and that a small-molecule JUN inhibitor (T-5224) decreases adhesion formation. Here, we encapsulated T-5224 in a shear-thinning hydrogel with antiadhesion properties for intraperitoneal postoperative delivery and sustained release of a JUN inhibitor for adhesion prevention. The material properties of the T-5224-hydrogel support its use for open or minimally invasive surgical application. We found this therapeutic system to be safe, well tolerated, and efficacious in murine and porcine preclinical models. T-5224-hydrogel minimized adhesion quantity and also diminished adhesion fibrosis at an ultrastructural level. Moving toward clinical translation, we developed a large mammal adhesion model in pigs with bowel resection. Single-cell transcriptomic analysis showed that JUN and associated pathway signaling were diminished in adhesion-derived fibroblasts treated with T-5224-hydrogel. The JUN-inhibiting T-5224-hydrogel provided robust prevention of adhesion without deleterious effects on bowel anastomosis or abdominal wall healing. Adhesion biology is similar across surgical sites, and, therefore, this formulation has potential for applicability across the body. The development of therapeutics to prevent adhesions is of paramount importance with potential for high-impact translation to patient care to address a common, unmet clinical need.

The role of peripheral perfusion index in predicting biphasic reactions in anaphylaxis patients

BACKGROUND/AIM

Anaphylaxis is a rapidly onset, life-threatening hypersensitivity reaction, and in some patients, a biphasic reaction may develop following initial treatment. This study aims to investigate the prognostic value of the peripheral perfusion index (PPI) in predicting biphasic reactions among patients presenting to the emergency department with anaphylaxis.

MATERIAL AND METHODS

The study is prospective and single-centered. A total of 104 patients aged 18 years and older, diagnosed with anaphylaxis in the emergency department, were included. PPI values, along with other vital signs, were measured at 0, 10, 20, and 30 min, as well as after symptom resolution. All patients were observed for a minimum of 6 h to monitor for the development of biphasic reactions.

RESULTS

The median PPI value at the 0-min mark was 2.20 (IQR, 1.52-3.67), while the median PPI value after symptom resolution was 4.20 (IQR, 3.10-6.35). A biphasic reaction occurred in 10.6 % of patients. Among patients who developed a biphasic reaction, PPI values at 0, 10, 20, and 30 min were significantly lower compared to those who did not (p < 0.05). In ROC analysis, a PPI cutoff of ≤2.17 for predicting biphasic reactions yielded 57 % sensitivity and 91 % specificity (AUC = 0.75).

CONCLUSION

PPI may serve as an accessible and cost-effective test in emergency departments for continuous monitoring of patients diagnosed with anaphylaxis, allowing for assessment of treatment response, early detection of biphasic reactions, and risk evaluation.

Successful Surgical Repair of Complete Duodenal Transection Caused by Horse Kick: A Case Report

INTRODUCTION

Horse kicks are a rare cause of injury and tend to cause severe complications such as visceral organ injury. Traumatic duodenal injuries are associated with high mortality rates. Furthermore, their reconstructive procedures vary widely and require appropriate on-the-spot judgment by the surgeon. We experienced a case of blunt abdominal trauma with a complete transection of the first portion of the duodenum caused by a horse kick without any associated lesions. A good postoperative course was achieved by trimming the pyloric part of the stomach and performing an end-to-end anastomosis between the gastric remnant and the duodenum, along with tube decompression and biliary drainage.

CASE PRESENTATION

A woman in her 50s was kicked in the right upper quadrant of her abdomen by a horse and transported to a local hospital. Computed tomography revealed pneumoperitoneum and hematoma near the duodenum, discontinuity of the duodenal wall, and a poorly contrasted area in the pancreas head. The patient underwent emergent laparotomy 6h after the accident. The first portion of the duodenum was completely lacerated. No contamination around the pancreatic head or saponification of fat tissue was observed. Because the patient's vital signs were stable and the condition of the damaged tissue was favorable, the transection was repaired with trimming of the pyloric part of the stomach and end-to-end anastomosis between the gastric remnant and the duodenum. Decompression, feeding and biliary drainage tubes were placed. The patient's postoperative course was favorable and the patient was discharged on postoperative day 20 in a stable condition. At an outpatient visit 3 months postoperatively, the patient reported no abdominal pain or stenosis symptoms.

CONCLUSIONS

We experienced a rare case of a single complete duodenal transection due to a horse kick. End-to-end anastomosis with tube decompression and biliary drainage was performed because the patient's vital signs were stable, there was little contamination or contusion of the surrounding tissue, and it had not been >24h since the injury. The patient had a good course of treatment.

Caffeine-clarithromycin coadministration and hyperlactatemia in a young infant: a case report

Apnea is a major complication of acute respiratory tract infection in young infants and may lead to the need for ventilatory support. Caffeine is methylxanthine, which is considered the mainstay of pharmacologic treatment for apnea of prematurity. On the basis of neonatal guidelines, caffeine has been used as a respiratory stimulant for the treatment of acute respiratory tract infection-related apnea, despite low evidence of its ability to improve clinical outcomes. Hyperlactatemia has been reported in adults with caffeine poisoning. Clarithromycin acts as an inhibitor of human cytochrome P450 and may impair drug metabolism. However, there are no published data concerning lactic acidosis associated with caffeine-clarithromycin coadministration. We report a case of hyperlactatemia in a young infant born prematurely who presented to the emergency department with acute respiratory tract infection-associated apnea and who required noninvasive ventilatory support. Because respiratory viruses were not detected in the nasopharyngeal aspirates and the chest radiography revealed interstitial opacities, clarithromycin (15mg/kg/day) was started via a nasoduodenal tube. In polysomnography, dysmaturity and immaturity of the central nervous system were evident. Hence, caffeine treatment was initiated at a loading dose of 10mg/kg followed by a maintenance dose of 5mg/kg/day. After treatment initiation, the child experienced ventilatory improvement and apnea control. However, a progressive increase in the serum lactate concentration and high anion gap metabolic acidosis were observed, despite hemodynamic stability. Following discontinuation of both drugs, the serum concentrations of lactate gradually returned to normal values. Thus, clarithromycin-caffeine coadministration may cause a sharp increase in lactate concentrations and should be avoided in young infants with acute respiratory tract infection-associated apnea.

Key interventions and outcomes in perioperative care pathways in emergency laparotomy: a systematic review

INTRODUCTION

Emergency laparotomy (EmLap) is a complex clinical arena, delivering time-sensitive, definitive care to a high-risk patient cohort, with significant rates of post-operative morbidity and mortality. Embedding perioperative care pathways within this complex setting has the potential to improve post-operative outcomes, however, requires an in-depth understanding of their design, delivery and outcome assessment. Delivering and implementing complex interventions such as perioperative pathways require transparent reporting with detailed and indepth description of all components during the assessment and evaluation phase. The aim of this systematic review was to identify the current design and reporting of perioperative pathways in the EmLap setting.

METHODS

The OVID SP versions of MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials were searched between January 1950 and December 2023. All randomised and non-randomised cohort studies reporting outcomes on perioperative care pathways in adult patients (> 18 years old) undergoing major emergency abdominal surgery were included. A narrative description of all perioperative pathways included was reported to identify design and description of the pathway including the delivery and timing of component interventions. All pathways were evaluated against the Template for Intervention Description and Replication (TIDieR) checklist.

RESULTS

Eleven RCTs and 19 non-randomised studies were identified, with most studies considered to be at moderate risk of bias. Twenty-six unique pathways were identified and described, delivering a total of 400 component interventions across 44,055 patients. Component interventions were classified into 24 domains across the perioperative pathway. Twenty studies (66.6%) did not report the TIDieR framework items, with thirteen studies reporting less than 50% of all items. Two hundred and fifty individual outcomes were reported across pathways, with the most commonly reported outcomes related to morbidity, mortality and length of stay.

CONCLUSION

Current perioperative pathways in EmLap setting are underpinned by variable component interventions, with a lack of in-depth intervention reporting and evaluation. Future studies should incorporate the TIDieR checklist when reporting on perioperative pathways in the EmLap setting.

CLINICAL TRIAL NUMBER

Not applicable.

Systemic capillary leak syndrome: a nosological entity that the nephrologist must be aware of

Capillary leak syndrome occurs when plasma leaks out of capillaries into muscles, tissues, organs and body cavities. There are two major types of capillary leak syndrome: 1. secondary capillary leak syndrome: it is a single episode triggered by another disease, condition or drug; 2. idiopathic systemic capillary leak syndrome: it is a rare disease characterized by recurrent episodes of acute life-threatening episodes of shock, hemoconcentration, and hypoalbuminemia. An increase in capillary permeability results in reversible plasma movement into the interstitial spaces followed by the appearance of related symptoms or complications, including acute kidney injury. Cytokines are likely to be important in the pathophysiology of systemic capillary leak syndrome. Fluid management is a critical part of the treatment of systemic capillary leak syndrome: hypovolemia and hypotension can cause organ injury, whereas capillary leakage of administered fluid can worsen organ edema leading to progressive organ injury.Although systemic capillary leak syndrome is a rare entity, it can be life-threatening. The nephrologist must be aware of the potential and serious complications linked to this pathology, including the need for kidney replacement therapy. This review aims to increase awareness of systemic capillary leak syndrome in the nephrology community.

Prognostic impact of hypernatremia for septic shock patients in the intensive care unit

BACKGROUND

Hypernatremia represents a significant electrolyte imbalance associated with numerous adverse outcomes, particularly in cases of intensive care unit (ICU)-acquired hypernatremia (IAH). Nevertheless, its relevance in patients with septic shock remains uncertain.

AIM

To identify independent risk factors and their predictive efficacy for IAH to improve outcomes in patients with septic shock.

METHODS

In the present retrospective single-center study, a cohort of 157 septic shock patients with concurrent hypernatremia in the ICU at The First Affiliated Hospital of Soochow University, between August 1, 2018, and May 31, 2023, were analyzed. Patients were categorized based on the timing of hypernatremia occurrence into the IAH group (n = 62), the non-IAH group (n = 41), and the normonatremia group (n = 54).

RESULTS

In the present study, there was a significant association between the high serum sodium concentrations, excessive persistent inflammation, immunosuppression and catabolism syndrome and chronic critical illness, while rapid recovery had an apparent association with normonatremia. Moreover, multivariable analyses revealed the following independent risk factors for IAH: Total urinary output over the preceding three days [odds ratio (OR) = 1.09; 95%CI: 1.02-1.17; P = 0.014], enteral nutrition (EN) sodium content of 500 mg (OR = 2.93; 95%CI: 1.13-7.60; P = 0.027), and EN sodium content of 670 mg (OR = 6.19; 95%CI: 1.75-21.98; P = 0.005) were positively correlated with the development of IAH. Notably, the area under the curve for total urinary output over the preceding three days was 0.800 (95%CI: 0.678-0.922, P = 0.001). Furthermore, maximum serum sodium levels, the duration of hypernatremia, and varying sodium correction rates were significantly associated with 28-day in-hospital mortality in septic shock patients (P < 0.05).

CONCLUSION

The present findings illustrate that elevated serum sodium level was significantly associated with a poor prognosis in septic shock patients in the ICU. It is highly recommended that hypernatremia be considered a potentially important prognostic indicator for the outcome of septic shock.

Mesenteric ischemia with intrasplenic gas: A case report

BACKGROUND

Acute mesenteric ischemia is a life-threatening disease. Intrasplenic gas is an extremely rare finding in such cases.

CASE SUMMARY

We report a case of a 79-year-old woman with a history of end-stage renal disease on hemodialysis for approximately 20 years, type 2 diabetes mellitus, and atrial fibrillation who presented with two days of epigastric pain. A computed tomography scan of the abdomen revealed intraperitoneal free air and significant intrasplenic gas. Laparoscopy revealed diffuse intestinal gangrene, and acute superior mesenteric ischemia was diagnosed. The patient died within 24 hours owing to profound shock.

CONCLUSION

Intrasplenic gas is an extremely rare finding on computed tomography imaging in cases of acute mesenteric ischemia.

In-hospital mortality of heat-related disease associated with wet bulb globe temperature: a Japanese nationwide inpatient data analysis

Heat-related diseases have become a significant public health concern. Studies have shown that susceptibility to heat varies among regions; however, most studies used aggregated data on emergency transport in the regions. The present study used a nationwide inpatient database in Japan and examined the association between regional differences in Wet Bulb Globe Temperature (WBGT) and in-hospital mortality in patients with a heat-related disease, with adjustment for individual-level characteristics. We retrospectively identified participants from the Japanese Diagnosis Procedure Combination inpatient database during the five warmest months of the year (May 1 to September 30) from 2011 to 2019. We calculated the long-term average daily maximum WBGT for the prefectures and categorized the prefectures into three areas (low-, middle-, and high-WBGT). We conduced multivariable logistic regression analyses to compare in-hospital mortality between the WBGT areas, adjusting for individual-level covariates (including age, sex, body mass index, and comorbidities). A total of 82,250 patients were admitted for heat-related diseases. The mean age was 63.2 (standard deviation, 25.0) years, and 63.7% were male. In the multivariable logistic regression analysis, the low-WBGT area had a higher in-hospital mortality than that had by the high-WBGT area (odds ratio, 1.32; 95% confidence interval, 1.15-1.52), whereas no significant difference was observed between the middle- and high-WBGT areas (odds ratio, 1.00; 95% confidence interval, 0.89-1.12). After adjusting for individual-level risk factors, in-hospital death was more likely to occur in patients with heat-related diseases in lower WBGT areas compared with those in higher WBGT areas.

Association Between No-Flow Time, Prehospital Low-Flow Time, and Conversion to Nonshockable Rhythm in Patients With Out-of-Hospital Cardiac Arrest Presenting With Initial Shockable Rhythm: A Nationwide Prospective Study in Japan

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) with initial shockable rhythm generally has a favorable prognosis. However, the prognosis worsens when this rhythm transitions to nonshockable rhythm on hospital arrival. This study aimed to investigate the association between no-flow time (NFT), prehospital low-flow time (LFT), and the conversion to nonshockable rhythm on hospital arrival in patients with OHCA initially exhibiting shockable rhythm.

METHODS

We analyzed adult patients with OHCA from the JAAM-OHCA (Japanese Association for Acute Medicine Out-of-Hospital Cardiac Arrest) registry (June 2014-December 2020) with initial shockable rhythm. The primary outcome was rhythm conversion to nonshockable on hospital arrival. Adjusted odds ratios (aORs) with 95% CIs were calculated using a logistic model to examine the associations between NFT, prehospital LFT, and rhythm conversion.

RESULTS

Of 68 110 patients, 3720 patients were included in our analysis. On hospital arrival, 27.9% patients achieved return of spontaneous circulation, 32.8% maintained shockable rhythm, and 39.3% transitioned to nonshockable rhythm (718 to pulseless electrical activity, 744 to asystole). Median NFT was 4 minutes (interquartile range [IQR], 1-9 minutes), and median prehospital LFT was 22 minutes (IQR, 14-31 minutes). Longer NFT and prehospital LFT were associated with higher aORs of rhythm conversion: NFT (5-9 minutes: aOR, 1.38 [95% CI, 1.14-1.67]; ≥10 minutes: aOR, 1.75 [95% CI, 1.44-2.14]); and prehospital LFT (15-19 minutes: aOR, 2.56 [95% CI, 2.00-3.27]; 20-29 minutes, aOR, 4.73 [95% CI, 3.83-5.85]; ≥30 minutes, aOR, 6.85 [95% CI, 5.49-8.56]).

CONCLUSIONS

Prolonged NFT and prehospital LFT were significantly associated with rhythm conversion to nonshockable on hospital arrival in patients with OHCA with initial shockable rhythm at the scene.

Anticoagulation in venovenous extracorporeal membrane oxygenation

Venovenous extracorporeal membrane oxygenation (VV-ECMO) is a lifesaving therapy in severe acute respiratory distress syndrome (ARDS). Unfortunately, bleeding and thrombotic complications occur regularly due to coagulation disorders associated with the device, the underlying disease, and the anticoagulation management. To facilitate a personalized approach to hemostasis in individuals receiving ECMO support, it is essential to assess the coagulative state of the patient while simultaneously taking into account the underlying medical condition and administered therapies.

Complement system activation through the alternative pathway associates with disseminated intravascular coagulation to increase mortality in sepsis

BACKGROUND

Sepsis-induced disseminated intravascular coagulation (DIC) increases mortality in sepsis patients. Complement system activation is concomitant with sepsis-induced DIC; however, it is unclear how these two pathologies influence clinical parameters of sepsis individually and in combination, and which of the complement pathways activation is predominantly associated with mortality.

METHODS

In this ancillary analysis of a prospective observational study, 49 adult sepsis patients were assigned to four groups according to the absence/presence of DIC and complement activation. Effects of complement activation and DIC on clinical demographics including parameters of DIC, systemic severities, and 60-days all-cause mortality were assessed by comparing the groups. We analyzed each complement pathway by comparing Bb, C3a/C3 ratio, SC5b-9/C3 ratio, C4d, C4d/C4 ratio, C3a, C5a, and SC5b-9 between survivors/non-survivors both in all the patients and in the DIC+ subgroup.

RESULTS

Complement system activation induced thrombocytopenia and enhanced sepsis severity measured as APACHE2 and SOFA scores. 60-days all-cause mortality was different between groups, with 0 % in the complement activation alone group, 14 % in the DIC alone group and 66 % in the combined DIC and complement activation group. Bb and C3a/C3 and SC5b-9/C3 ratios were higher in non-survivors, with Bb and SC5b-9/C3 ratio still higher in DIC+ non-survivors.

CONCLUSION

Complement activation worsen the severity of sepsis and cause thrombocytopenia. Co-occurrence of complement activation and DIC increased sepsis mortality. The alternative pathway of complement activation plays a major role in sepsis mortality.

Risk Factors and Preventive Measures of Venous Thromboembolism in Trauma Patients using Trauma Embolic Scoring System: A retrospective chart review

BACKGROUND

Venous thromboembolism (VTE) is a major preventable complication in trauma patients, with varying incidence and risk factors across populations.

AIM/OBJECTIVE

To categorize VTE risk in Korean trauma patients using the Trauma Embolic Scoring System (TESS) and assess the application of prophylaxis by risk level.

METHODS

This retrospective study at Korea University Guro Hospital involved 1913 trauma patients over two years. Data on demographics, injury specifics, and preventive treatments were analyzed using TESS. The study examined general, mechanical, and chemical interventions for VTE prevention.

RESULTS

Of the patients, 1.4% were diagnosed with VTE. The average TESS score was 3.20, indicating lower injury severity but higher percentages of surgeries over 2 h and serious injuries. The findings showed VTE occurrences even in patients with TESS scores below the high-risk threshold, particularly in limb injuries. Nurse-led interventions like early physical activity were most common in the low-risk group, while mechanical prophylaxis like anti-embolism stockings was also predominantly used in this group. Chemical prophylaxis showed consistent administration across groups, with 37.5% of the high-risk group receiving Low Molecular Weight Heparin (LMWH), although only a minority received it within the recommended 48-hour.

CONCLUSIONS

The study reveals a need for vigilant monitoring and intervention across all risk categories, underscoring the importance of tailored VTE prevention guidelines in South Korea. It highlights the role of comprehensive management, including patient education and adherence to updated guidelines.

TWEETABLE ABSTRACT

New study categorizes VTE risk in Korean trauma patients using TESS, showing the need for tailored prophylaxis across risk levels #VTEPrevention #TraumaCare.

The Caregiver Pathway Intervention Can Contribute to Reduced Post-Intensive Care Syndrome Among Family Caregivers of ICU Survivors: A Randomized Controlled Trial

OBJECTIVES

Explore short-term effects of "The Caregiver Pathway," an intervention for family caregiver follow-up, on Post-Intensive Care Syndrome symptoms among families (PICS-F).

DESIGN

A randomized controlled trial.

SETTING

A medical ICU at a Norwegian University Hospital.

PARTICIPANTS

One hundred ninety-six family caregivers of critically ill patients randomized to an intervention ( n = 101) or control group ( n = 95).

INTERVENTIONS

"The Caregiver Pathway" four-step model offers individual and structured follow-up, including: 1) mapping family caregivers' needs and concerns with an assessment tool followed by a conversation with an ICU nurse within the first days at the ICU, 2) a supportive card when leaving the ICU, 3) offer for the family caregivers to receive a phone call after ICU patient discharge, and 4) a follow-up conversation within 3 months.

MEASUREMENTS AND MAIN RESULTS

Data were collected at baseline and after 3 months and analyzed using linear regression. No significant effects were detected when comparing all participants completing 3-month outcome measurements ( n = 144). A subgroups analysis stratified on patient survival, however, showed statistically significant effect for family caregivers of patients surviving the ICU stay receiving the intervention compared with controls. Caregivers of surviving patients reported improved symptoms related to post-traumatic stress disorder, measured by Impact of Event Scale-Revised (B = -8.2 [95% CI, -14.2 to -2.2]; p = 0.008), anxiety (B = -2.2 [95% CI, -4.0 to -0.5]; p = 0.014), and depression (B = -1.5 [95% CI, -2.9 to -0.1]; p = 0.035); measured by the Hospital Anxiety and Depression Scale, subscore physical functioning in health-related quality of life (B = 9.7 [95% CI, 0.3-19.0]; p = 0.043); measured by Short Form 12-Item Health Survey; and hope (B = 2.4 [95% CI, 0.4-4.3]; p = 0.017) and measured by the Herth Hope Index. At 3-month, the model did not appear to improve the outcomes for family caregivers of nonsurviving patients.

CONCLUSIONS

"The Caregiver Pathway" intervention was associated with reduced symptoms of PICS-F in family caregivers of surviving ICU patients compared with controls.

Therapeutic potential of DNases in immunothrombosis: promising succor or uncertain future?

Sepsis, a life-threatening condition characterized by systemic inflammation and multiorgan dysfunction, is closely associated with the excessive formation of neutrophil extracellular traps (NETs) and the release of cell-free DNA. Both play a central role in sepsis progression, acting as major contributors to immunothrombosis and associated complications. Endogenous DNases play a pivotal role in degrading NETs and cell-free DNA, yet their activity is often dysregulated during thrombotic disease. Although exogenous DNase1 administration has shown potential in reducing NET burden and mitigating the detrimental effects of immunothrombosis, its therapeutic efficacy upon intravenous administration remains uncertain. The development of engineered DNase formulations and combination therapies may further enhance its therapeutic effectiveness by modifying its pharmacodynamic properties and avoiding the adverse effects associated with NET degradation, respectively. Although NETs are well-established targets of DNase1, it remains uncertain whether the positive effects of DNase1 on immunothrombosis are exclusively related to it's targeting of NETs or if other components contributing to immunothrombosis are also affected. This review examines the endogenous regulation of NETs in circulation and the therapeutic potential of DNases in immunothrombosis, underscoring the necessity for further investigation to optimize their clinical application.

Treatment outcomes in non-occlusive mesenteric ischemia and post-treatment return to social activities

PURPOSE

To investigate the treatment outcomes of patients with non-occlusive mesenteric ischemia (NOMI) at our institution, we focused on their post-treatment return to social activities.

METHODS

This study included patients with suspected NOMI who were referred to our department between 2011 and 2023. In-hospital mortality was also investigated as a prognostic factor. The Glasgow-Pittsburgh Outcome Categories (GPOC) score was used to evaluate the return to social activities. The relationship between in-hospital mortality and GPOC scores and patient background and treatment factors was examined.

RESULTS

Eighty-two patients were included in the study. Among them, 54 (65.9%) died during hospitalization. Only 9 patients (11%) returned to their social activities. In the multivariate analysis, non-surgical management was found to be the only independent factor for in-hospital mortality. Positive portal venous gas on computed tomography, no open abdomen, no pre-onset catecholamine administration, platelet count < 100,000/µL, lactate level < 5 mmol/L, APTT < 46 s, and Sequential Organ Failure Assessment score < 11 were factors significantly associated with an increased likelihood of return to social activities.

CONCLUSION

This is the first study to assess the post-treatment return to social activities among patients with NOMI. Our findings highlight the concerning reality that survivors may face prolonged dependence on medical care.

The implementation and impact of narrative diaries in neonatal intensive care units: A scoping review

BACKGROUND

Premature birth and the Neonatal Intensive Care Unit (NICU) experience can be challenging for parents, affecting their psychological and emotional well-being. NICU diaries could help to reduce the separation gap and strengthen the bonding process with their infant.

AIM

To review the literature on narrative diaries, definitions and use in the NICU.

STUDY DESIGN

We conducted a scoping review following the Joanna Briggs Institute (JBI) methodology. We searched PubMed, Embase, Scopus, PsycINFO, Cinahl, and Grey Literature up to September 2024. Studies reporting on the use or effect of narrative diaries in the NICU were included. A descriptive and thematic analysis was conducted.

RESULTS

Of a total of 526 records, 21 were included. Most studies had a quasi-experimental or qualitative design, including a framework conceptualization. Editorials were common. Mothers (33%), nurses (9%) and fathers (5%) were the most common diarists. Seven studies evaluated the effect of NICU diaries on family post-intensive care syndrome (PICS-F), satisfaction, and family separation. The benefits of NICU diaries for parents included improved communication, empowerment, personal emotional awareness and parental closeness with their newborn, while for staff, they reduced burnout and fostered the humanization of care. Acceptability was high.

CONCLUSIONS

Acceptability and perceived benefits of NICU diaries were widely reported. Heterogeneity in aims, use, and follow-up was high. Well-designed effective multicentre studies providing evidence of impact on PICS-F and a position statement framing the intervention in NICU are recommended.

RELEVANCE TO CLINICAL PRACTICE

This study has shown that NICU diaries have the potential to improve humanization, communication between NICU staff and parents, parents' coping, and closeness to their newborn.

Sepsis-associated endothelial glycocalyx damage: a review of animal models, clinical evidence, and molecular mechanisms

In the mammalian cardiovascular system, endothelial glycocalyx is a gel-like layer that covers the luminal surface of endothelial cells (ECs) and plays crucial roles in vascular homeostasis, permeability and leukocyte adhesion. Degradation of this structure occurs early in sepsis and becomes accordingly dysfunctional. In severe cases, it is not self-regulated by the organism. However, the relationship between the glycocalyx and the occurrence and development of sepsis remains poorly understood. One possibility is that thinned glycocalyx promotes leukocyte recognition and adhesion, thereby facilitating the elimination of pathogens from infected areas. This may represent a protective mechanism developed by the organism during through evolutionary processes. However, if the damage persists and disrupts the dynamic balance of the microcirculation, interstitial edema or organ failure can occur. Thus, we asked the questions, what is the precise composition and structure of the glycocalyx? How is it degraded? What animal models are available to study the relationship between the glycocalyx and sepsis? What glycocalyx biomarkers are found in the blood of patients with sepsis? To determine whether sepsis can be treated by interfering with the glycocalyx, this study provides a systematic summary and discussion of the latest progress in addressing these questions.

Prehospital Cricothyrotomy: A Narrative Review of Technical, Educational, and Operational Considerations for Procedure Optimization

BACKGROUND

Definitive airway management is a requisite skill in the prehospital setting, most often accomplished with either an endotracheal tube or supraglottic airway. When clinicians encounter a cannot oxygenate and cannot ventilate scenario, a patient's airway still must be secured. Prehospital cricothyrotomy is a high acuity, low frequency procedure used to secure the airway through the anterior neck. Patients who require cricothyrotomy often have significant comorbid conditions and mortality, and there can be a high rate of procedural complications. The ability to perform a cricothyrotomy is within the scope of practice for many prehospital clinicians and mastery of the procedure is crucial for patient outcomes. Despite this, initial training on the procedure is minimal, and paramedics report discomfort in their ability to perform the procedure.

OBJECTIVE

Review and summarize the best available evidence relating to the performance of cricothyrotomies and propose technical, educational, and operational considerations to minimize complications and optimize success of prehospital cricothyrotomies.

DISCUSSION

Technical considerations when performing cricothyrotomy in the prehospital setting can be used to mitigate airway misplacement, mainstem intubation, and hemorrhage. Educational consideration should include focus on a singular technique, use of established curriculum, spaced repetition with either simulation or mental practice, and a focus on intention training of when to perform the procedure. The preferred technique from the National Association of Emergency Medical Service (EMS) Physician guidelines is the surgical technique. Operational considerations to optimize a successful procedure should include checklists, preassembled kits, and robust quality improvement and insurance after a cricothyrotomy is performed.

CONCLUSIONS

By focusing on technical, educational, and operation considerations relating to prehospital cricothyrotomy, prehospital clinicians can optimize the chance for procedural success.

Nasogastric Tube Syndrome: A Case Report of otalgia and hoarseness in a Palliative Care Setting

BACKGROUND

Nasogastric tube syndrome (NGTS) is a rare but potentially life-threatening complication of nasogastric tube (NGT) placement. It is characterized by throat pain, hoarseness, and vocal cord paralysis. Awareness is essential for preventing severe airway compromise.

CASE PRESENTATION

A 57-year-old woman with pseudomyxoma peritonei developed NGTS while admitted to a palliative care unit with a prolonged NGT placement for intestinal obstruction. The patient presented with symptoms including throat pain, otalgia, and subsequent hoarseness. Fiberoptic laryngoscopy revealed restricted vocal cord abduction and posterior pharyngeal erythema. Despite the option of removing the NGT, it was retained due to ongoing drainage needs and the absence of respiratory distress. Conservative management, including corticosteroids, antibiotics, and proton pump inhibitors, led to symptom resolution.

CONCLUSION

This case emphasizes the importance of recognizing NGTS, particularly in palliative care settings, and highlights the need for vigilance for atypical symptoms like otalgia. Conservative management may be effective in selected cases, underscoring the importance of individualized care and increased awareness among clinicians.

Investigating Dose Level and Duration of Rehabilitation of Mechanically Ventilated Patients in the ICU

Background: The dose level and duration needed for early rehabilitation of mechanically ventilated patients in the ICU need to be characterized. Therefore, this study aimed to assess the association between mobilization level, rehabilitation time, and dose (defined as the mean mobilization quantification score [MQS]) during ICU admission and the end point walking independence at hospital discharge in subjects needing ICU admission. Methods: This prospective, multi-center, cohort study included 9 ICUs. Consecutive subjects admitted to the ICU between September 2022-March 2023 receiving mechanical ventilation for >48 h were included in the study. The mean MQS score, highest ICU mobility score (IMS) during the ICU stay, time to the first mobilization day, ICU rehabilitation time (minutes of each rehabilitation physical activity from start to finish), frequency/d, baseline characteristics, and walking independence at hospital discharge were assessed. Results: Among the 116 subjects, 64 did and 51 did not walk independently at hospital discharge, respectively. Multiple logistic regression analysis revealed that the mean MQS and time to first mobilization were significantly associated with walking independence at hospital discharge. We observed that mean MQS was better than IMS, rehabilitation time, frequency, and time to first mobilization predicted walking independence based on receiver operating characteristic (ROC) curve comparison. Comparison of the mean MQS with that on the first mobilization day revealed superior predicting power of the mean MQS. The ROC curve cutoff value for the mean MQS was 4.0. Conclusions: This study shows that in subjects mechanically ventilated for >48 h the dose of rehabilitation calculated using the mean MQS during ICU was a better predictor of walking independence at hospital discharge than intensity, duration, or frequency of the mobilization therapy. Mean MQS during ICU stay may be used to measure and titrate optimal mobilization therapy.