Mechanism and treatment of intracerebral hemorrhage focus on mitochondrial permeability transition pore

Intracerebral hemorrhage (ICH) is the second most common subtype of stroke, characterized by high mortality and a poor prognosis. Despite various treatment methods, there has been limited improvement in the prognosis of ICH over the past decades. Therefore, it is imperative to identify a feasible treatment strategy for ICH. Mitochondria are organelles present in most eukaryotic cells and serve as the primary sites for aerobic respiration and energy production. Under unfavorable cellular conditions, mitochondria can induce changes in permeability through the opening of the mitochondrial permeability transition pore (mPTP), ultimately leading to mitochondrial dysfunction and contributing to various diseases. Recent studies have demonstrated that mPTP plays a role in the pathological processes associated with several neurodegenerative diseases including Parkinson's disease, Alzheimer's disease, Huntington's disease, ischemic stroke and ischemia-reperfusion injury, among others. However, there is limited research on mPTP involvement specifically in ICH. Therefore, this study comprehensively examines the pathological processes associated with mPTP in terms of oxidative stress, apoptosis, necrosis, autophagy, ferroptosis, and other related mechanisms to elucidate the potential mechanism underlying mPTP involvement in ICH. This research aims to provide novel insights for the treatment of secondary injury after ICH.

Emergency Call versus General Practitioner Requested Ambulances - Patient Mortality, Disease Severity and Pattern

Introduction

Ambulance requests by general practitioners for primary care patients (GP-requested) are often omitted in studies on increased demand within emergency care but may comprise a substantial patient group. We aimed to assess acute severity, intensive care unit (ICU) admission, and diagnostic pattern, including comorbidity, and mortality among GP-requested ambulance patients, compared to emergency call ambulance patients. Our hypothesis was that emergency call patients had more severe health issues than GP-requested ambulance patients.

Methods

Historic population-based cohort study of ambulance patients in the North Denmark Region, 2016-2020. Hospital contact data including diagnoses, ambulance data, vital signs and vital status was linked using each patient's unique identification number. Primary outcome measure was mortality within 1, 7, and 30 days. Secondary outcomes were disease severity expressed as modified National Early Warning Score (NEWS2), and ICU admission. Admission status and hospital diagnostic pattern, including comorbidity were described and compared.

Results

We included 255,487 patients. GP-requested patients (N = 119,361, 46.7%) were older (median years [IQR] 73 [58-83] versus 61 [37-76]) and more had moderate/severe comorbidity (11.9%, N = 13,806 versus 4.9%, N = 6145) than the emergency call patients. Prehospital mNEWS2 median scores were lower for GP-requested patients. For both groups, mNEWS2 was highest among patients aged 66+. GP-requested patients had higher 30-day mortality (9.0% (95% CI: 8.8-9.2), N = 8996) than emergency call patients (5.2% (95% CI: 5.1-5.4), N = 6727). Circulatory (12.0%, 11,695/97,112) and respiratory diseases (11.6%, 11,219/97,112) were more frequent among GP-requested patients than emergency call patients ((10.7%, 12,640/118,102) and (5.8%, 6858/118,102)). The highest number of deaths was found for health issues 'circulatory diseases' in the emergency call group and 'other factors' followed by "respiratory diseases" in the GP-requested group.

Conclusion

GP-requested patients constituted nearly half of the EMS volume, they were older, with more comorbidity, had serious conditions with substantial acute severity, and a higher 30-day mortality than emergency call patients.

An engineered lactate oxidase based electrochemical sensor for continuous detection of biomarker lactic acid in human sweat and serum

Lactate levels in humans reveal intensity and duration of exertion and provide a critical readout for the severity of life-threatening illnesses such as pediatric sepsis. Using the lactate oxidase enzyme (Lox) from Aerococcus viridians, we demonstrated its functionality for lactate electrochemical sensing in physiological fluids in a lab setting. The structure and dynamics of LOx were validated by crystallography, X-ray scattering, and hydroxyl radical protein footprinting. This provided a validated protein template for understanding and designing an enzyme-based electrochemical sensing elements. Using this template, LOx enzyme variants were generated and compared. Comparison of the variants demonstrates that one exhibits effective lactate sensing at significantly reduced operating voltages. Additionally, we demonstrate that the four hexahistidine-tags on each enzyme tetramer are sufficient for immobilization to create a durable, functional sensor, with no need for a covalent attachment, enabling self-immobilization and eliminating the need for additional immobilization steps. The functionality of the LOx enzyme variants was verified at physiological lactate concentrations in both human serum (0-4 mM) and artificial sweat (0-100 mM) using 3-electrode setups for analysis of the three variants in parallel. Accuracy of measurement in both artificial sweat and human serum were high. Employing a microfluidic flow cell, we successfully monitored varying lactate levels in physiological fluids continuously over a 2h period. Overall, this optimized LOx enzyme, which self-immobilizes onto gold sensing electrodes, facilitates efficient and reliable lactate detection and continuous monitoring at reduced operating voltages suitable for further development towards commercial use.

Attitudes and Skills in Basic Life Support after Two Types of Training: Traditional vs. Gamification, of Compulsory Secondary Education Students: A Simulation Study

It is recommended to implement the teaching of Basic Life Support (BLS) in schools; however, studies on the best training method are limited and have been a priority in recent years. The objective of this study was to analyze the attitudes and practical skills learned during BLS training using a gamified proposal. A comparative study was carried out, consisting of Compulsory Secondary Education students [control group (CG; classical teaching) and experimental group (EG; gamified proposal)]. The instruments used were the CPR and AED action sequence observation sheet, data from the Laerdal Resusci Anne manikin and AED and Attitude Questionnaire towards Basic Life Support and the Use of the Automated External Defibrillator. Sixty-eight students (33 girls) with a mean age of 13.91 ± 0.70 years were recruited. Results were significantly better in the EG (n = 37) [i.e., breathing control (p = 0.037); call to emergency services (p = 0.049); mean compression depth (p = 0.001); self-confidence (p = 0.006); intention to perform BLS and AED (p = 0.002)]; and significantly better in the CG (n = 31) [Total percentage of CPR (p < 0.001); percentage of correct compression (p < 0.001); time to apply effective shock with AED (p < 0.001); demotivation (p = 0.005). We can conclude that the group that was trained with the training method through the gamified proposal presents better intentions and attitudes to act in the event of cardiac arrest than those of the classic method. This training method allows for similar results in terms of CPR and AED skills to classical teaching, so it should be taken into account as a method for teaching BLS to secondary education students.

Relationship between coagulopathy score and ICU mortality: Analysis of the MIMIC-IV database

Objective

Coagulopathy score has been applied as a new prognostic indicator for sepsis, heart failure and acute respiratory failure. However, its ability to forecast intensive care unit (ICU) mortality in patients with an acute cerebral hemorrhage (ICH) has not been assessed. The purpose of this study was to clarify the relationship between ICU mortality and early coagulation problem score.

Methods

Data from the Medical Information Mart for Intensive Care (MIMIC-IV) (v2.0) database were used in this retrospective cohort analysis. The association between the coagulation disorder score and ICU mortality was examined using multivariate logistic regression. Furthermore, the impact of additional variables on the results was investigated by a subgroup analysis.

Results

3174 patients (57.3 % male) were enrolled in total. The ICU mortality reached 18.2 %. After adjusting for potential confounders, the ICU mortality of patients rose with the increase of coagulation disorder score. The ROC curve revealed the predictive accuracy of coagulation dysfunction score to mortality in patients with ICU. The coagulation disorder score had a lower AUC value (0.601, P < 0.001) than the SAPSII(AUCs of 0.745[95 % CI, 0.730-0.761]) and the combined indicators(AUCs of 0.752[95 % CI, 0.737-0.767]), but larger than single indicators platelet, INR and APTT. In the subgroup analysis, most subgroups showed no significant interaction, but only age showed significant interaction in the adjusted model.

Conclusion

The coagulopathy score and ICU mortality were found to be strongly positively correlated in this study, and its ability to predict ICU mortality was better than that of a single measure (platelet, INR, or APTT), but worse than that of the SAPSII score, GCS system.

Management of spontaneous pneumothorax: a mini-review on its latest evidence

Spontaneous pneumothorax usually presents as a medical emergency and requires prompt attention and treatment. In patients with underlying lung diseases, it is often associated with prolonged hospitalization, persistent air leak and also a high rate of recurrence. It brings considerable clinical burden to patients and therefore advancement of spontaneous pneumothorax management is eagerly anticipated. In recent years, conservative approach with avoidance of invasive treatment has risen to be a main consideration for primary spontaneous pneumothorax (PSP) patients who are clinically stable with minimal symptoms. The body of evidence in secondary spontaneous pneumothorax (SSP) group is less robust compared with that in PSP group. Non-surgical treatment in SSP is becoming more common due to concerns about morbidity and mortality after surgical pleurodesis as patients are usually older with more underlying medical diseases. Until last year, there have been no updates on the international recommendation of pneumothorax management since the British Thoracic Society (BTS) guideline published in 2010. The latest 2023 BTS guideline on pleural diseases provides us a good opportunity to review the latest development and literature of the care for patients with spontaneous pneumothorax. This article will explore the goals of pneumothorax treatment including air evacuation, cessation of persistent air leak and prevention of recurrence.

Nutritional therapy for the prevention of post-intensive care syndrome

Post-intensive care syndrome (PICS) is a triad of physical, cognitive, and mental impairments that occur during or following the intensive care unit (ICU) stay, affecting the long-term prognosis of the patient and also the mental health of the patient's family. While the severity and duration of the systemic inflammation are associated with the occurrence of ICU-acquired weakness (ICU-AW), malnutrition and immobility during the treatment can exacerbate the symptoms. The goal of nutrition therapy in critically ill patients is to provide an adequate amount of energy and protein while addressing specific nutrient deficiencies to survive the inflammatory response and promote recovery from organ dysfunctions. Feeding strategy to prevent ICU-AW and PICS as nutrition therapy involves administering sufficient amounts of amino acids or proteins later in the acute phase after the hyperacute phase has passed, with specific attention to avoid energy overfeeding. Physiotherapy can also help mitigate muscle loss and subsequent physical impairment. However, many questions remain to be answered regarding the potential role and methods of nutrition therapy in association with ICU-AW and PICS, and further research is warranted.

Delayed traumatic intracranial aneurysms: literature review and case series

Traumatic intracranial aneurysm (TICA) is a rare and aggressive pathology that requires prompt treatment. Nevertheless, early vascular imaging following head trauma may yield falsely negative results, underscoring the importance of subsequent imaging within the first week to detect delayed TICAs. This study aims to report our experience with delayed TICAs and highlight the clinical importance of repeated angiographic screening for delayed TICAs. In this retrospective analysis, we evaluated patients managed for a TICA at a tertiary care teaching institution over the last decade. Additionally, we conducted a systematic review of the literature, following the PRISMA guidelines, on previously reported TICAs, focusing on the time lag between the injury and diagnosis. Twelve delayed TICAs were diagnosed in 9 patients. The median time interval from injury to diagnosis was 2 days (IQR: 1-22 days), and from diagnosis to treatment was 2 days (IQR: 0-9 days). The average duration of radiological follow-up was 28 ± 38 months. At the final follow-up, four patients exhibited favorable neurological outcomes, while the remainder had adverse outcomes. The mortality rate was 22%. Literature reviews identified 112 patients with 114 TICAs, showcasing a median diagnostic delay post-injury of 15 days (IQR: 6-44 days), with 73% diagnosed beyond the first week post-injury. The median time until aneurysm rupture was 9 days (IQR: 3-24 days). Our findings demonstrate acceptable outcomes following TICA treatment and highlight the vital role of repeated vascular imaging after an initial negative computed tomography or digital subtraction angiography in excluding delayed TICAs.

Association of prehospital lactate levels with base excess in various emergencies - a retrospective study

OBJECTIVES

Blood gas analysis, including parameters like lactate and base excess (BE), is crucial in emergency medicine but less commonly utilized prehospital. This study aims to elucidate the relationship between lactate and BE in various emergencies in a prehospital setting and their prognostic implications.

METHODS

We conducted a retrospective analysis of prehospital emergency patients in Graz, Austria, from October 2015 to November 2020. Our primary aim was to assess the association between BE and lactate. This was assessed using Spearman's rank correlation and fitting a multiple linear regression model with lactate as the outcome, BE as the primary covariate of interest and age, sex, and medical emergency type as confounders.

RESULTS

In our analysis population (n=312), lactate and BE levels were inversely correlated (Spearman's ρ, -0.75; p<0.001). From the adjusted multiple linear regression model (n=302), we estimated that a 1 mEq/L increase in BE levels was associated with an average change of -0.35 (95 % CI: -0.39, -0.30; p<0.001) mmol/L in lactate levels. Lactate levels were moderately useful for predicting mortality with notable variations across different emergency types.

CONCLUSIONS

Our study highlights a significant inverse association between lactate levels and BE in the prehospital setting, underscoring their importance in early assessment and prognosis in emergency care. Additionally, the findings from our secondary aims emphasize the value of lactate in diagnosing acid-base disorders and predicting patient outcomes. Recognizing the nuances in lactate physiology is essential for effective prehospital care in various emergency scenarios.

UCH-L1 Inhibitor Alleviates Nerve Damage Caused by Moyamoya Disease

Background

Moyamoya disease (MMD) leads to nerve injury. Exosomes are touted as bio-shuttles for the delivery of distinct biomolecules inside the cells. Recently, UCH-L1 was shown to play a vital role in nerve injury. However, it is still unknown whether UCH-L1 can improve the nerve injury of MMD.

Materials and Methods

Exosomes were isolated from the serum of patients with MMD and healthy controls. The total RNA was extracted from the exosomes, and the level of GFAP and UCH-L1 between the serum exosomes of the two groups was analyzed by a quantitative reverse transcription-polymerase chain reaction and western blot. Exosome labeling and uptake by SH-SY5Y cells were observed by confocal laser microscopy. Cell counting kit-8 assay and flow cytometry were used to determine the viability and apoptosis of SH-SY5Y cells, respectively.

Results

Exosomes were successfully isolated and identified from serum. The expression of GFAP and UCH-L1 was significantly higher in the serum-derived exosomes from MMD patients compared with the healthy controls (P  < 0.05). Compared to the blank and control exosome group, serum-derived exosomes from MMD significantly suppress cellular vitality and promote apoptosis of SH-SY5Y cells, while the use of LDN-91946, a specific inhibitor of UCH-L1, could reverse the effects induced by serum-derived exosomes from MMD.

Conclusion

UCH-L1 inhibitor could reverse MMD-induced inhibition of SH-SY5Y cell viability and promotion of apoptosis. UCH-L1 may be a therapeutic target for the treatment of nerve damage caused by MMD.

Video Versus Nonvideo in a Rabbit Training Model for Establishing an Emergency Front of Neck Airway in Children: A Prospective Trial

OBJECTIVES

Simulating a realistic "cannot intubate, cannot oxygenate" (CICO) situation to train an "emergency front of neck airway" is difficult. It further remains unclear if provision of regular technical refreshers improves performance in the setting of a real CICO situation. The purpose of this prospective study on an established surgical rabbit cadaver tracheostomy model was to evaluate the benefit of viewing training material shortly before performing "emergency front of neck airway."

METHODS

Previously trained participants were randomized into 2 groups. The control group (video) was allowed to watch an instructional video before performing a tracheotomy on the training model, while the study group (nonvideo) was not. Queried outcomes included success rate, performance time, and severe secondary airway injuries between the 2 groups.

RESULTS

In 29 tracheotomies performed by 29 participants, the overall success rate was 86% (92% video; 81% nonvideo, P = 0.4). Performance time was not different between the 2 groups (video: 80 s [IQR25-75: 53-86], nonvideo 64 s [IQR25-75: 47-102]; P = 0.93). Only in the nonvideo group, the performance time and the time between the workshops correlated positively (P = 0.048). Severe secondary injuries were noted in 4 of 29 rabbit cadavers, 2 in each group. Watching a refresher video before performing an emergency surgical tracheostomy in an infant training model did not influence the success rate and the performance time in previously trained anesthetists.

CONCLUSIONS

These results highlight the ease of learning, memorization, and recall of this emergency surgical tracheostomy technique and may demonstrate its applicability in a real infant CICO situation.

Inside-out, antimicrobial resistance mediated by efflux pumps in clinical strains of Acinetobacter baumannii isolated from burn wound infections

Acinetobacter baumannii belongs to the ESKAPE group. It is classified as a critical priority group by the World Health Organization and a global concern on account of its capacity to acquire and develop resistance mechanisms to multiple antibiotics. Data from the United States indicates 500 deaths annually. Resistance mechanisms of this bacterium include enzymatic pathways such as ß-lactamases, carbapenemases, and aminoglycoside-modifying enzymes, decreased permeability, and overexpression of efflux pumps. A. baumannii has been demonstrated to possess efflux pumps, which are classified as members of the MATE family, RND and MFS superfamilies, and SMR transporters. The aim of our work was to assess the distribution of efflux pumps and their regulatory gene expression in clinical strains of A. baumannii isolated from burned patients. METHODS: From the Clinical Microbiology Laboratory at the Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra collection in Mexico, 199 strains were selected. Antibiotics susceptibilities were performed by broth microdilutions to determine minimal inhibitory concentrations. Phenotypic assays with efflux pump inhibitors were conducted using carbonyl cyanide 3-chlorophenylhydrazone (CCCP) and phenylalanine-arginine ß-naphthylamide (PAßN) in conjunction with amikacin, ceftazidime, imipenem, meropenem and levofloxacin. A search was conducted for structural genes that are linked to efflux pumps, and the relative expression of the adeR, adeS, and adeL genes was analyzed. RESULTS: Among a total of 199 strains, 186 exhibited multidrug resistance (MDR). Fluoroquinolones demonstrated the highest resistance rates, while minocycline and amikacin displayed comparatively reduced resistance rates (1.5 and 28.1, respectively). The efflux activity of fluorquinolones exhibited the highest phenotypic detection (from 85 to 100%), while IMP demonstrated the lowest activity of 27% with PAßN and 43.3% with CCCP. Overexpression was observed in adeS and adeL, with adeR exhibiting overexpression. Concluding that clinical strains of A. baumannii from our institution exhibited efflux pumps as one of the resistance mechanisms.

A Prospective Study of the Association of IL6 with the Critical Unit and Their Effect on in-Hospital Mortality in Critically Ill Patients

Purpose

We previously proposed a new concept, the "critical unit", which covers the structural integrity and function of mitochondria and endothelium. Injury of the critical unit plays a key role in the development of critical illnesses. High levels of inflammation may lead to abnormalities of the critical unit, which is an important mechanism for critical illnesses, and both inflammation and critical unit dysfunction may affect patient prognosis. Here we evaluated the correlation between interleukin-6 (IL6) and the critical unit biomarkers in critically ill patients and the impact of both on prognosis.

Patients and Methods

This study included adult patients admitted to the intensive care unit for various reasons from January 1st to May 31st, 2023. Baseline characteristics, intensive care unit parameters, and laboratory test and outcome data were obtained from the electronic medical records system. Critical unit parameters were measured using polymerase chain reaction and enzyme-linked immunosorbent assay methods. Correlations were examined between IL6, critical unit parameters, and various outcomes.

Results

In critically ill patients, IL6 was closely associated with all the critical unit biomarkers (activated partial thromboplastin time, sphingosine 1-phosphate, mitochondrial DNA, mitochondrial fission 1, and Parkin) and the prognoses of patients. A nomogram was constructed using the critical unit biomarkers to predict the in-hospital mortality of critically ill patients. The area under the curve for the mortality prediction model was 0.708. In sensitivity analyses, the predictive effect was better in the non-surgery and tumor groups compared with the surgery and non-tumor groups, with area under the curve values of 0.885 and 0.891, respectively.

Conclusion

Our study innovatively integrated mitochondrial and endothelial markers in the critical unit to comprehensively evaluate patient prognosis, which may be a trend in the future assessment of critically ill patients. There are few such studies, and ours may promote the progress of related research.

A novel AVPR2 gene mutation in a Chinese pedigree with nephrogenic diabetes insipidus

Nephrogenic diabetes insipidus (NDI) is a rare genetic disorder primarily associated with mutations in the arginine vasopressin receptor 2 (AVPR2) gene or the aquaporin 2 (AQP2) gene, resulting in impaired water reabsorption in the renal tubules. This report describes a case of a young male patient with NDI from China with a history of polydipsia and polyuria for over 15 years. Laboratory examinations of the proband indicated low urine-specific gravity and osmolality. Urologic ultrasound revealed severe bilateral hydronephrosis in both kidneys, bilateral dilatation of the ureters, roughness of the bladder wall, and the formation of muscle trabeculae. The diagnosis of diabetes insipidus was confirmed by water deprivation tests. The administration of posterior pituitary hormone did not alter urine-specific gravity, and osmolality remained at a low level (<300 mOsm/kg). Based on these findings, and the genetic tests of the proband and his parents were performed. A missense mutation (c.616 G>C) in exon 3 of the AVPR2 gene of the proband was found, caused by the substitution of amino acid valine to leucine at position 206 [p.Val206Leu], which was a hemizygous mutation and consistent with X-chromosome recessive inheritance. The administration of oral hydrochlorothiazide improves the symptoms of polydipsia and polyuria in the proband. This novel AVPR2 gene mutation may be the main cause of NDI in this family, which induces a functional defect in AVPR2, and leads to reduced tubular reabsorption of water.

Differences in outcomes of patients with out-of-hospital cardiac arrest treated with extracorporeal cardiopulmonary resuscitation between day-time and night-time

Although patients who underwent night-time resuscitation for out-of-hospital cardiac arrest (OHCA) had worse clinical outcomes than those who underwent day-time resuscitation, the differences between the outcomes of patients with OHCA who underwent extracorporeal cardiopulmonary resuscitation (ECPR) in the day-time and night-time remain unclear. We analyzed data from the Study of Advanced Life Support for Ventricular Fibrillation with Extracorporeal Circulation in Japan. Patients were categorized according to whether they received treatment during the day-time or night-time. The primary outcomes were survival to hospital discharge and favorable neurological outcome at discharge, and the secondary outcomes were estimated low-flow time, implementation time of ECPR, and complications due to ECPR. A multivariate logistic regression model adjusted for confounders was used for comparison. Among the 1644 patients, the night-time patients had a significantly longer ECMO implementation time and estimated low-flow time than the day-time patients, along with a significantly higher number of complications than the day-time patients. However, the survival and neurologically favorable survival rates did not differ significantly between the groups. Thus, although patients who underwent ECPR at night had an increased risk of longer implementation time and complications, their clinical outcomes did not differ from those who underwent day-time ECPR.

Prolonged Fatigue and Mental Health Challenges in Critical COVID-19 Survivors

Background: The aim of this study was to investigate the development of fatigue and mental illness between 3 and 12 months after critical COVID-19 and explore risk factors for long-lasting symptoms. Study Design and Methods: A prospective, multicenter COVID-19 study in southern Sweden, including adult patients (≥18 years) with rtPCR-confirmed COVID-19 requiring intensive care. Survivors were invited to a follow-up at 3 and 12 months, where patient-reported symptoms were assessed using the Modified Fatigue Impact Scale (MFIS), the Hospital Anxiety and Depression Scale (HADS) and the Posttraumatic Stress Disorder Checklist version 5 (PCL-5). The development between 3 and 12 months was described by changes in relation to statistical significance and suggested values for a minimally important difference (MID). Potential risk factors for long-lasting symptoms were analyzed by multivariable logistic regression. Results: At the 3-month follow-up, 262 survivors (87%) participated, 215 (72%) returned at 12 months. Fatigue was reported by 50% versus 40%, with a significant improvement at 12 months (MFIS; median 38 vs. 33, P < .001, MID ≥4). There were no significant differences in symptoms of mental illness between 3 and 12 months, with anxiety present in 33% versus 28%, depression in 30% versus 22%, and posttraumatic stress disorder in 17% versus 13%. A worse functional outcome and less sleep compared to before COVID-19 were risk factors for fatigue and mental illness at 12 months. Conclusions: Fatigue improved between 3 and 12 months but was still common. Symptoms of mental illness remained unchanged with anxiety being the most reported. A worse functional outcome and less sleep compared to before COVID-19 were identified as risk factors for reporting long-lasting symptoms.

Performance of 21 Early Warning System scores in predicting in-hospital deterioration among undifferentiated admitted patients managed by ambulance services

BACKGROUND

The optimal Early Warning System (EWS) scores for identifying patients at risk of clinical deterioration among those transported by ambulance services remain uncertain. This retrospective study compared the performance of 21 EWS scores to predict clinical deterioration using vital signs (VS) measured in the prehospital or emergency department (ED) setting.

METHODS

Adult patients transported to a single ED by ambulances and subsequently admitted to the hospital between 1 January 2019 and 18 April 2019 were eligible for inclusion. The primary outcome was 30-day mortality; secondary outcomes included 3-day mortality, admission to intensive care or coronary care units, length of hospital stay and emergency call activations. The discriminative ability of the EWS scores was assessed using the area under the receiver operating characteristic curve (AUROC). Subanalyses compared the performance of EWS scores between surgical and medical patient types.

RESULTS

Of 1414 patients, 995 (70.4%) (53.1% male, mean age 68.7±17.5 years) were included. In the ED setting, 30-day mortality was best predicted by VitalPAC EWS (AUROC 0.71, 95% CI (0.65 to 0.77)) and National Early Warning Score (0.709 (0.65 to 0.77)). All EWS scores calculated in the prehospital setting had AUROC <0.70. Rapid Emergency Medicine Score (0.83 (0.73 to 0.92)) and New Zealand EWS (0.88 (0.81 to 0.95)) best predicted 3-day mortality in the prehospital and ED settings, respectively. EWS scores calculated using either prehospital or ED VS were more effective in predicting 3-day mortality in surgical patients, whereas 30-day mortality was best predicted in medical patients. Among the EWS scores that achieved AUROC ≥0.70, no statistically significant differences were detected in their discriminatory abilities to identify patients at risk of clinical deterioration.

CONCLUSIONS

EWS scores better predict 3-day as opposed to 30-day mortality and are more accurate when estimated using VS measured in the ED. The discriminatory performance of EWS scores in identifying patients at higher risk of clinical deterioration may vary by patient type.

AI-Assisted Detection of Biomarkers by Sensors and Biosensors for Early Diagnosis and Monitoring

The steady progress in consumer electronics, together with improvement in microflow techniques, nanotechnology, and data processing, has led to implementation of cost-effective, user-friendly portable devices, which play the role of not only gadgets but also diagnostic tools. Moreover, numerous smart devices monitor patients' health, and some of them are applied in point-of-care (PoC) tests as a reliable source of evaluation of a patient's condition. Current diagnostic practices are still based on laboratory tests, preceded by the collection of biological samples, which are then tested in clinical conditions by trained personnel with specialistic equipment. In practice, collecting passive/active physiological and behavioral data from patients in real time and feeding them to artificial intelligence (AI) models can significantly improve the decision process regarding diagnosis and treatment procedures via the omission of conventional sampling and diagnostic procedures while also excluding the role of pathologists. A combination of conventional and novel methods of digital and traditional biomarker detection with portable, autonomous, and miniaturized devices can revolutionize medical diagnostics in the coming years. This article focuses on a comparison of traditional clinical practices with modern diagnostic techniques based on AI and machine learning (ML). The presented technologies will bypass laboratories and start being commercialized, which should lead to improvement or substitution of current diagnostic tools. Their application in PoC settings or as a consumer technology accessible to every patient appears to be a real possibility. Research in this field is expected to intensify in the coming years. Technological advancements in sensors and biosensors are anticipated to enable the continuous real-time analysis of various omics fields, fostering early disease detection and intervention strategies. The integration of AI with digital health platforms would enable predictive analysis and personalized healthcare, emphasizing the importance of interdisciplinary collaboration in related scientific fields.

Practical approach to thrombocytopenia in patients with sepsis: a narrative review

Thrombocytopenia frequently occurs in patients with sepsis. Disseminated intravascular coagulation (DIC) may be a possible cause of thrombocytopenia owing to its high prevalence and association with poor outcomes; however, it is important to keep the presence of other diseases in mind in sepsis practice. Thrombotic microangiopathy (TMA), which is characterized by thrombotic thrombocytopenic purpura, Shiga toxin-producing Escherichia coli hemolytic uremic syndrome (HUS), and complement-mediated HUS, is characterized by thrombocytopenia, microangiopathic hemolytic anemia, and organ damage. TMA has become widely recognized in recent years because of the development of specific treatments. Previous studies have reported a remarkably lower prevalence of TMA than DIC; however, its epidemiology is not well defined, and there may be cases in which TMA is not correctly diagnosed, resulting in poor outcomes. Therefore, it is important to differentiate DIC from TMA. Nevertheless, differentiating between DIC and TMA remains a challenge as indicated by previous reports that most patients with TMA can be diagnosed as DIC using the universal coagulation scoring system. Several algorithms to differentiate sepsis-related DIC from TMA have been suggested, contributing to improving the care of septic patients with thrombocytopenia; however, it may be difficult to apply these algorithms to patients with coexisting DIC and TMA, which has recently been reported. This review describes the disease characteristics, including epidemiology, pathophysiology, and treatment, of DIC, TMA, and other diseases with thrombocytopenia and proposes a novel practical approach flow, which is characterized by the initiation of the diagnosis of TMA in parallel with the diagnosis of DIC. This practical flow also refers to the longitudinal diagnosis and treatment flow with TMA in mind and real clinical timeframes. In conclusion, we aim to widely disseminate the results of this review that emphasize the importance of incorporating consideration of TMA in the management of septic DIC. We anticipate that this practical new approach for the diagnostic and treatment flow will lead to the appropriate diagnosis and treatment of complex cases, improve patient outcomes, and generate new epidemiological evidence regarding TMA.

Viscolin-mediated antiapoptotic and neuroprotective effects in cortical neurons exposed to oxygen-glucose deprivation and rats subjected to transient focal cerebral ischemia

OBJECTIVE

Previously, we have successfully purified and synthesized viscolin, an agent derived from Viscum coloratum extract, which has shown significant potential in the treatment of stroke. Our study aimed to evaluate the neuroprotective effects of viscolin.

METHODS

We first assessed the cytotoxicity of viscolin on primary neuronal cultures and determined its antioxidant and radical scavenging properties. Subsequently, we identified the optimal dose-response of viscolin in protecting against glutamate-induced neurotoxicity.

RESULTS

Our results demonstrated that viscolin at a concentration of 10 μM effectively reduced neuronal cell death up to 6 hours after glutamate-induced neurotoxicity. Additionally, we investigated the therapeutic window of opportunity and the potential of viscolin in preventing necrotic and apoptotic damage in cultured neurons exposed to oxygen glucose deprivation-induced neurotoxicity. Our findings showed that viscolin treatment significantly reduced DNA breakage, prevented the release of cytochrome c from mitochondria to cytosol, increased the expression of anti-apoptotic protein Bcl-2, decreased the expression of pro-apoptotic protein Bax, and reduced the number of TUNEL-positive cells. Additionally, our in vivo investigation demonstrated a reduction in brain infarction following middle cerebral artery occlusion.

CONCLUSION

Viscolin has potential utility as a therapeutic agent in the treatment of stroke.

Correlation of preoperative inflammatory factors and emotional disorders with postoperative delirium in patients with craniocerebral trauma

BACKGROUND

Traumatic brain injury (TBI) imposes a substantial societal and familial burden due to its high disability and fatality rates, rendering it a serious public health problem. Some patients with TBI have poor treatment outcomes and are prone to postoperative delirium (POD), which affects their quality of life. Anxiety has been linked to increased POD incidence in some studies, while others have found no correlation.

AIM

To investigate the correlation of POD risk factors, preoperative inflammatory factors, and mood disorders in patients with TBI.

METHODS

We retrospectively collected data on the treatment of 80 patients with TBI from November 2021 to September 2023. Patients were grouped as POD and non-POD, according to their POD status, and the general data of the two groups were compared. Inflammatory factor levels were detected preoperatively, and the Hamilton Depression Scale (HAMD) and Hamilton Anxiety Scale (HAMA) were used to investigate the risk factors associated with POD in these patients. Logistic regression was used to identify the independent risk factors.

RESULTS

Twenty-one patients (26.25%) developed POD, including 7, 10, and 4 cases of the excitatory, inhibitory, and mixed types, respectively. There were 59 cases (73.75%) in the non-POD group. Compared with the non-POD group, the POD group had a significantly higher proportion of patients with low Glasgow Coma Scale (GCS) scores before admission, unilateral mydriasis, preoperative hemorrhagic shock, intraventricular hemorrhage (IVH), and postoperative hyperglycemic hyperosmolar disease (P < 0.05). In the POD group, interleukin-6 (IL-6), human tumor necrosis factor-α (TNF-α), myeloperoxidase levels, HAMA, and HAMD scores were higher than those in the non-POD group (all P < 0.05). Logistic multivariate analysis showed that GCS score at admission, IVH, IL-6, TNF-α, HAMA, and HAMD were independent risk factors for POD in patients with TBI (P < 0.05).

CONCLUSION

Low GCS score at admission, IVH, elevated IL-6 and TNF-α, other inflammatory indicators, anxiety, and depression, can increase the risk of POD in patients with TBI after surgery.

Blood-based protein biomarkers during the acute ischemic stroke treatment window: a systematic review

Background

Rapid and accurate acute ischemic stroke (AIS) diagnosis is needed to expedite emergent thrombolytic and mechanical thrombectomy treatment. Changes in blood-based protein biomarkers during the first 24 h of AIS, the time window for treatment, could complement imaging techniques and facilitate rapid diagnosis and treatment.

Methods

We performed a systematic review according to PRISMA guidelines. MEDLINE, EMBASE, Cochrane Library, and Web of Science databases were searched for eligible studies comparing levels of blood-based protein biomarkers in AIS patients with levels in healthy controls and stroke mimics. Protein biomarkers from the following pathophysiological categories were included: neurovascular inflammation (MMP-9, TNF-alpha), endothelial integrity (VCAM-1, ICAM-1), cell migration (E-Selectin, P-Selectin, L-Selectin), markers of glial and neuronal origin (GFAP, S100, S100B, NSE), and cardiac dysfunction (BNP, NT-proBNP). The literature search was limited to English-language publications before November 7th, 2023.

Results

A total of 61 studies from 20 different countries were identified, which included in total, 4,644 AIS patients, 2,242 stroke mimics, and 2,777 controls. Studies investigating TNF-alpha, MMP-9, VCAM-1, ICAM-1, E-Selectin, L-Selectin, GFAP, NSE, and S100B showed pronounced methodological heterogeneity, making between-study comparisons difficult. However, in 80% of NT-proBNP and BNP studies, and all P-selectin studies, higher biomarker levels were observed in AIS patients compared to healthy controls and/or patients with stroke mimics.

Conclusion

None of the biomarkers included showed sufficient evidence for additional diagnostic benefit for AIS. Comprehensive standardized global multicenter studies are needed to (1) permit comparability, (2) enable valid statements about protein-based biomarkers, and (3) reflect real-world scenarios.

Case Report: Surgical challenges and insights in a child with a blunt left diaphragmatic and pericardial rupture and heart subluxation

Introduction

Blunt diaphragmatic rupture (BTDR) is a rare condition that can occur in children following high-energy blunt thoracoabdominal trauma. In less than 1% of the cases, pericardial rupture can coexist with a BTDR. A coexistence of BTDR and pericardial rupture can result in displacement of the heart and is associated with high mortality. Clinical presentation is non-specific and requires a high index of suspicion for early management.

Case presentation

A 4-year-old child presented to the emergency unit of our hospital following high-energy trauma with severe respiratory distress. Initially, a left-side chest tube was inserted, but it resulted in no clinical improvement. A chest x-ray showed a collapse of the left lung with a herniation of bowel loops into the left hemithorax. An exploratory laparotomy was done, which revealed a 10 cm × 4 cm defect in the left hemidiaphragm with a medial extension involving the pericardium. The fundus of the stomach and left lobe of the liver were displaced into the pericardial space, pushing the cardiac apex posteriorly to the right side. Concomitantly, the transverse colon and small bowel were displaced into the left pleural space. After the reduction of the herniated abdominal viscera back into the peritoneal cavity, the pericardial sac was repaired by employing an interrupted resorbable suture, while the diaphragmatic defect was repaired by using a horizontal mattress. No other injuries were identified and the abdomen was closed in layers.

Conclusion

BTDR with pericardial rupture is an elusive condition with a high mortality rate that necessitates a high index of clinical suspicion. Early surgical repair of the defect with a reduction of herniated organs can reduce morbidity and mortality.

Health Statuses of People in Poverty Receiving Public Assistance in Japan: A Scoping Review

Background

Promoting health and well-being is essential to ensure dignified lives of the entire population, including those living in poverty. Guaranteeing the human right to health is a critical responsibility of social security policies. To address emerging issues associated with poverty, the Japanese government has implemented a welfare program known as public assistance-seikatsu-hogo. However, financial welfare programs may not fully mitigate health risks due to the complex impact of poverty on health. Although a global systematic review of the health status of public and social assistance recipients has been conducted, it did not include any studies from Japan. Furthermore, evidence for the development of health support strategies for Japanese recipients remains scarce. This scoping review aims to identify the current situation and potential issues concerning the health of recipients.

Methods

PubMed was searched for articles published before November 2023. Of the 357 articles identified, 56 were included. Among those included, 35 used the individual status of receiving public assistance as an exposure variable, 13 considered public assistance recipients as the study population, and 8 used the prefectural proportion of the population receiving public assistance as an environmental predictor.

Results

We found that public assistance recipients tend to have more disadvantageous health and well-being statuses than the general population, as reported in the global systematic review. Health inequalities were also observed among recipients based on their sociodemographic characteristics. In Japan, public assistance recipients face several health risks and are at a disadvantage compared with the general population.

Conclusions

The distribution of risks is heterogeneous among recipients, despite the minimum income protection and financial benefits in health and long-term care use. Further studies to identify the effects of public assistance policy on the health of the impoverished population, evidence-based discussions, and reform of social security policies are warranted.

Analysis of high-risk factors and mortality prediction of ruptured abdominal aortic aneurysm

INTRODUCTION

Ruptured abdominal aortic aneurysms (RAAAs) are among the most dangerous emergencies in vascular surgery, with a high death rate and numerous risk factors influencing perioperative death. Therefore, identifying the critical risk factors for RAAAs is crucial to increasing their survival rate. Our aim was to identify those risk factors from a wide range of parameters.

METHODS

Retrospective analysis of hospitalised RAAA patients treated at this center between May 2004 and January 2023. After comparing the preoperative data of patients who survived and those who died, high-risk characteristics influencing the perioperative care of RAAA patients were identified, and logistic regression analysis was carried out. The mean follow-up time was 45.34 months.

RESULTS

During the study period, a total of 155 patients (average age 67.4±71.93 years, 123 (78.85%)males, 32 (20.51%)females) were enrolled. The patients participating in the group were divided into survival group (n = 123) and death group (n = 27). The main differences included hemodynamic instability (51.9% vs 28.5%; P=0.019), sudden cardiac arrest (14.8% vs 1.6%; P=0.010), deterioration of consciousness (40.7% vs 17.1%; P=0.007), renal impairment (22.2% vs 2.4%; P=0.001), chronic kidney disease (18.5% vs3.2%; P=0.010). There is also a history of cancer (Ca) (18.5% vs 4.1%; P=0.021). Risk factors for Endovascular aneurysm repair (EVAR) include diastolic blood pressure ≤ 50 mmHg (36.4% vs 8.0%; P=0.025), renal function impairment (18.2% vs 0; P=0.015), and chronic kidney disease (27.3% vs 4.0%; P=0.028). Risk factors for open surgical repair (OSR) include diastolic blood pressure ≤ 50 mmHg (40.0% vs 6.3%; P=0.014). Finally, the above statistically significant factors were analyzed by Logistic regression analysis, and it was found that diastolic blood pressure ≤ 50mmHg, cardiac arrest, renal function damage and Ca history were independent risk factors. We followed 123 individuals and 14 were lost to follow-up, with an overall survival rate of 43.8%.

CONCLUSION

Hemodynamics, which includes shock, blood pressure, cardiac arrest, deterioration of consciousness, and other conditions, are the primary risk factors for the perioperative death of a ruptured abdominal aortic aneurysm. Simultaneously, diastolic blood pressure ≤50mmHg was found to be associated with risk factors for OSR, whereas renal function impairment, chronic renal illness, and diastolic blood pressure ≤50mmHg were associated with risk for EVAR.

Case report of pharmacokinetic analysis of continuous intravenous infusion of fentanyl in a patient with severe burn: burn shock stage complicates pain management

BACKGROUND

Fentanyl is widely used as an analgesic and sedative for patients with severe burn injuries in intensive care units. However, pharmacokinetic (PK) data for fentanyl, particularly for continuous intravenous infusion during the acute phase of burn injuries, are limited. Here, we report the clinical course and changes in blood fentanyl concentrations during the acute phase in a patient with severe burns treated with continuous intravenous infusion of fentanyl.

CASE PRESENTATION

A woman in her 40s, with burns caused by a gas cylinder explosion, was transported to our hospital. The patient had burn wounds on face, neck, shoulders, and all four extremities, with a total burn area of 39.0%. For pain relief, the patient received a continuous infusion of 0.01 mg/mL fentanyl (20-30 µg/h) with a target blood concentration of 1.0-1.5 ng/mL, but continued to suffer from pain due to burning during the acute phase. We measured the blood fentanyl concentrations and found that all concentrations obtained during the acute phase were subtherapeutic. Notably, during the burn shock stage, blood concentrations of fentanyl were 0.50 ng/mL on day 1 and 0.66 ng/mL on day 2, indicating that the blood concentration did not rise sufficiently for the dosage. From days 0 to 2, the patient was administered a massive fluid load for burn shock. After the burn shock stage resolved, fentanyl concentrations gradually approached the target range, and the pain rating scale improved, even though the fentanyl administration rate remained unchanged (30 µg/h).

CONCLUSIONS

Major changes in the fluid volumes of body compartments that occur with large burns might increase the volume of fentanyl distribution, thereby lowering its concentration when a standard dose is administered. Our findings indicate that the PK of fentanyl in patients with severe burns can be substantially affected, especially during the shock phase, implying the importance of titrating analgesics for clinical efficacy in the acute phase.

Quantification of treprostinil concentration in rat and human using a novel validated and rapid liquid chromatography-tandem mass spectrometry method: Experimental and clinical applications in ischemia-reperfusion injury

Treprostinil (Remodulin®) is a Food and Drug Administration (FDA) approved prostacyclin analog to treat pulmonary arterial hypertension. Recently, treprostinil has been investigated to reduce ischemia-reperfusion injury (IRI) during transplantation, which currently has no approved treatment. A validated analytical method is necessary to measure treprostinil concentrations in biological specimens. Here, a novel, sensitive, and specific method to measure treprostinil concentrations in rat serum, human serum, and human plasma has been developed using liquid chromatography with tandem mass spectrometry (LC-MS/MS). Biological samples were processed by protein precipitation before chromatography and 6-keto Prostaglandin F1α-d4 was used as an internal standard. A gradient method was established with a total run time of 4 min. The assay was linear over the range of 0.25-75.0 ng/ml with accuracy (92.97-107.87 %), intra-assay precision (1.16-3.34 %), and inter-assay precision (1.11-4.58 %) in all biological matrices, which are within FDA acceptance criteria. No significant variation in treprostinil or 6-keto Prostaglandin F1α-d4 concentrations were observed under the investigated storage conditions. This novel, sensitive, and specific LC/MS-MS method is cost-effective and suitable for measuring treprostinil concentrations in animal studies and human biological samples for clinical applications.

Linoleic acid-derived diol 12,13-DiHOME enhances NLRP3 inflammasome activation in macrophages

12,13-dihydroxy-9z-octadecenoic acid (12,13-DiHOME) is a linoleic acid diol derived from cytochrome P-450 (CYP) epoxygenase and epoxide hydrolase (EH) metabolism. 12,13-DiHOME is associated with inflammation and mitochondrial damage in the innate immune response, but how 12,13-DiHOME contributes to these effects is unclear. We hypothesized that 12,13-DiHOME enhances macrophage inflammation through effects on NOD-like receptor protein 3 (NLRP3) inflammasome activation. To test this hypothesis, we utilized human monocytic THP1 cells differentiated into macrophage-like cells with phorbol myristate acetate (PMA). 12,13-DiHOME present during lipopolysaccharide (LPS)-priming of THP1 macrophages exacerbated nigericin-induced NLRP3 inflammasome activation. Using high-resolution respirometry, we observed that priming with LPS+12,13-DiHOME altered mitochondrial respiratory function. Mitophagy, measured using mito-Keima, was also modulated by 12,13-DiHOME present during priming. These mitochondrial effects were associated with increased sensitivity to nigericin-induced mitochondrial depolarization and reactive oxygen species production in LPS+12,13-DiHOME-primed macrophages. Nigericin-induced mitochondrial damage and NLRP3 inflammasome activation in LPS+12,13-DiHOME-primed macrophages were ablated by the mitochondrial calcium uniporter (MCU) inhibitor, Ru265. 12,13-DiHOME present during LPS-priming also enhanced nigericin-induced NLRP3 inflammasome activation in primary murine bone marrow-derived macrophages. In summary, these data demonstrate a pro-inflammatory role for 12,13-DiHOME by enhancing NLRP3 inflammasome activation in macrophages.

Characteristics of indoor and outdoor fatal hypothermia cases in Chiba, Japan

In forensic medicine, hypothermia is a frequently encountered cause of death, and this characteristic provides public health information to prevent similar deaths in the future. Previous studies revealed regional differences in hypothermia occurrence (indoors or outdoors). However, to our knowledge, no recent studies in Japan have directly compared the characteristics of indoor- and outdoor-onset cases based on forensic autopsy reports. Hence, this study aimed to determine the characteristics and risks of unexpected hypothermia-related death. It included 218 cases from the Chiba Prefecture, Japan, wherein forensic autopsies were performed and hypothermia was diagnosed; these cases were categorized into indoor- and outdoor-onset cases, and their characteristics were examined. The results showed no significant differences between the two groups in relation to the age of onset or residential environment (i.e., the presence or absence of cohabitants). The outdoor-onset group tended to have a higher incidence of dementia. Regarding the causes of hypothermia, the indoor group had more internal causes (p < 0.0001), whereas the outdoor group had more primary and external causes (p < 0.0001 and p = 0.0029, respectively). The indoor group was more undressed than the outdoor group. Atypical antipsychotic components were predominantly detected in the blood in the outdoor group (p = 0.0077). The body mass index tended to be lower in the indoor group than in the outdoor group. Broadening public awareness of the present study findings may aid in developing preventative strategies for hypothermia based on the location of onset.

Risk Factors, Pathogens, and Outcomes of Ventilator-Associated Pneumonia in Non-Cardiac Surgical Patients: A Retrospective Analysis

Ventilator-associated pneumonia (VAP) is a critical hospital-acquired infection following non-cardiac surgeries, leading to poor outcomes. This study identifies VAP risk factors in non-cardiac surgical patients and determines the causative pathogens. A retrospective analysis with 1:4 propensity-score matching was conducted on patients in a surgical intensive care unit (ICU) from 2010 to 2020 at a private tertiary medical center. Among 99 VAP patients, the mortality rate was 64.7%. VAP risk factors included prolonged mechanical ventilation (odds ratio [OR] 6.435; p < 0.001), repeat intubation (OR 6.438; p < 0.001), lower oxygenation levels upon ICU admission (OR 0.950; p < 0.001), and undergoing gastrointestinal surgery (OR 2.257; p = 0.021). The 30-day mortality risk factors in the VAP group were late-onset VAP (OR 3.450; p = 0.022), inappropriate antibiotic treatment (OR 4.083; p = 0.041), and undergoing gastrointestinal surgeries (OR 4.776; p = 0.019). Nearly half of the Gram-negative infections were resistant strains, and a third were polymicrobial infections. Non-cardiac surgical patients with VAP face adverse hospital outcomes. Identifying high-risk patients and understanding VAP's resistant and microbial nature are crucial for appropriate treatment and improved health outcomes.

Effect of polypharmacy on the outcomes of older patients with advanced non-small-cell lung cancer treated with PD-1/PD-L1 inhibitors: A retrospective cohort study

INTRODUCTION

The effect of polypharmacy on older patients with cancer is unclear. This study aimed to explore the effect of polypharmacy on the outcomes of treatment in older patients with advanced non-small cell lung cancer (NSCLC) treated with PD-1/PD-L1 inhibitors.

MATERIALS AND METHODS

We retrospectively reviewed the records of older patients (aged ≥65 years) with advanced NSCLC who received PD-1/PD-L1 inhibitors with or without platinum-based chemotherapy as first-line treatment from March 2016 to December 2020. Patients with driver oncogenes or Eastern Cooperative Oncology Group performance status (PS) ≥2 were excluded. Polypharmacy was defined as receiving five or more oral or inhaled medications at baseline. We compared the progression-free survival (PFS), overall survival (OS), and mean cumulative length of hospital stays between the polypharmacy and non-polypharmacy groups.

RESULTS

A total of 122 patients, with a median age of 72 years (range, 65-89 years), were included in the analysis. Of the patients, 34 (27.8%) had a PS of 0 and 68 (55.7%) had a PD-L1 tumor proportion score (TPS) of ≥50%. The median number of oral or inhaled medications was 4 (range, 0-12), and 60 (49.1%) patients were taking ≥5 medications (polypharmacy). Age and Charlson Comorbidity Index score were significantly higher in the polypharmacy group (P = 0.01 and P < 0.001, respectively). Compared with the non-polypharmacy group, the polypharmacy group had a similar median PFS (6.7 vs. 8.5 months, P = 0.94) and a shorter median OS (17.3 vs. 26.0 months, P = 0.04). In the polypharmacy group, the adjusted hazard ratio for OS (adjusted for age, PS, and PD-L1 TPS) was 1.65 (95% confidence interval, 1.04-2.86, P = 0.03). Patients in the polypharmacy group had longer hospital stays (46.3 ± 7.5 vs. 27.7 ± 4.1 days/person, P < 0.05) and more emergency hospitalizations (1.6 ± 0.3 vs. 0.8 ± 0.1 times/person, P < 0.05) during the first year.

DISCUSSION

Polypharmacy was associated with shorter survival time and longer hospitalization in older patients with advanced NSCLC receiving first-line immunotherapy with or without chemotherapy.

Role of the Stress Index in Predicting Mortality among Patients with Traumatic Femoral Fractures

BACKGROUND

Traumatic femoral fractures, often resulting from high-energy impacts such as traffic accidents, necessitate immediate management to avoid severe complications. The Stress Index (SI), defined as the glucose-to-potassium ratio, serves as a predictor of mortality and adverse outcomes in various trauma contexts. This study aims to evaluate the prognostic value of the SI in patients with traumatic femoral fractures.

METHODS

This retrospective cohort study included adult trauma patients aged 20 or above with traumatic femoral fractures from the Trauma Registry System at a level 1 trauma center in southern Taiwan between 1 January 2009 and 31 December 2022. At the emergency room, serum electrolyte levels were assessed using baseline laboratory testing. By dividing blood glucose (mg/dL) by potassium (mEq/L), the SI was calculated. The best cut-off value of the SI for predicting mortality was determined using the Area Under the Curve (AUC) of Receiver Operating Characteristic (ROC).

RESULTS

A total of 3717 patients made up the final group, of which 3653 survived and 64 died. In comparison to survivors, deceased patients had substantially higher blood glucose levels (199.3 vs. 159.0 mg/dL, p < 0.001) and SIs (53.1 vs. 41.6, p < 0.001). The optimal SI cut-off value for predicting mortality was 49.7, with a sensitivity of 53.1% and a specificity of 78.7% (AUC = 0.609). High SI was associated with increased mortality (4.2% vs. 1.0%, p < 0.001) and longer hospital stays (12.8 vs. 9.5 days, p < 0.001). The adjusted odds ratios of mortality, controlled by comorbidities, the Glasgow Coma Scale, and the Injury Severity Score, were significantly higher in patients with a higher SI (AOR 2.05, p = 0.016) than those with a lower SI.

CONCLUSIONS

Elevated SI upon admission correlates with higher mortality and extended hospital stay in patients with traumatic femoral fractures. Although the SI has a moderate predictive value, it remains a useful early risk assessment tool, necessitating further prospective, multi-center studies for validation and standardization.

The spectrum of anti-GQ1B antibody syndrome: beyond Miller Fisher syndrome and Bickerstaff brainstem encephalitis

INTRODUCTION

Since the initial identification of Miller Fisher syndrome (MFS) and Bickerstaff brainstem encephalitis (BBE),significant milestones have been achieved in understanding these diseases.Discoveries of common serum antibodies (IgG anti-GQ1b), antecedent infections, neurophysiological data, andneuroimaging suggested a shared autoimmune pathogenetic mechanism rather than distinct pathogenesis, leadingto the hypothesis that both diseases are part of a unified syndrome, termed "Fisher-Bickerstaff syndrome". The subsequent identification of atypical anti-GQ1b-positive forms expanded the classification to a broader condition known as "Anti-GQ1b-Antibody syndrome".

METHODS

An exhaustive literature review was conducted, analyzing a substantial body of research spanning from the initialdescriptions of the syndrome's components to recent developments in diagnostic classification and researchperspectives.

RESULTS

Anti-GQ1b syndrome encompasses a continuous spectrum of conditions defined by a common serological profilewith varying degrees of peripheral (PNS) and central nervous system (CNS) involvement. MFS and BBE represent theopposite ends of this spectrum, with MFS primarily affecting the PNS and BBE predominantly involving the CNS.Recently identified atypical forms, such as acute ophthalmoparesis, acute ataxic neuropathy withoutophthalmoparesis, Guillain-Barré syndrome (GBS) with ophthalmoparesis, MFS-GBS and BBE-GBS overlap syndromes,have broadened this spectrum.

CONCLUSION

This work aims to provide an extensive, detailed, and updated overview of all aspects of the anti-GQ1b syndromewith the intention of serving as a stepping stone for further shaping thereof. Special attention was given to therecently identified atypical forms, underscoring their significance in redefining the boundaries of the syndrome.

Emergency Patient Triage Improvement through a Retrieval-Augmented Generation Enhanced Large-Scale Language Model

OBJECTIVES

Emergency medical triage is crucial for prioritizing patient care in emergency situations, yet its effectiveness can vary significantly based on the experience and training of the personnel involved. This study aims to evaluate the efficacy of integrating Retrieval Augmented Generation (RAG) with Large Language Models (LLMs), specifically OpenAI's GPT models, to standardize triage procedures and reduce variability in emergency care.

METHODS

We created 100 simulated triage scenarios based on modified cases from the Japanese National Examination for Emergency Medical Technicians. These scenarios were processed by the RAG-enhanced LLMs, and the models were given patient vital signs, symptoms, and observations from emergency medical services (EMS) teams as inputs. The primary outcome was the accuracy of triage classifications, which was used to compare the performance of the RAG-enhanced LLMs with that of emergency medical technicians and emergency physicians. Secondary outcomes included the rates of under-triage and over-triage.

RESULTS

The Generative Pre-trained Transformer 3.5 (GPT-3.5) with RAG model achieved a correct triage rate of 70%, significantly outperforming Emergency Medical Technicians (EMTs) with 35% and 38% correct rates, and emergency physicians with 50% and 47% correct rates (p < 0.05). Additionally, this model demonstrated a substantial reduction in under-triage rates to 8%, compared with 33% for GPT-3.5 without RAG, and 39% for GPT-4 without RAG.

CONCLUSIONS

The integration of RAG with LLMs shows promise in improving the accuracy and consistency of medical assessments in emergency settings. Further validation in diverse medical settings with broader datasets is necessary to confirm the effectiveness and adaptability of these technologies in live environments.

Systemic capillary leak syndrome in a patient treated with nivolumab/ipilimumab immunotherapy for metastatic melanoma with concurrent COVID-19 vaccination

Systemic capillary leak syndrome (SCLS) is a rare and life-threatening disorder characterised by leaking of intravascular fluid to extravascular tissues. An association with immunotherapy and COVID-19 vaccination has been reported as potential triggers. A case of a patient in her 70s developing SCLS after the BNT162b2 (Pfizer-BioNTech) COVID-19 vaccination with a history of metastatic melanoma treated with nivolumab (PD-1 monoclonal antibody) and ipilimumab (anti-CTLA4 monoclonal antibody) is reported. The aetiology and management of SCLS are also reviewed in this case context.

Molecular Insight into Acute Limb Ischemia

Acute limb ischemia (ALI) is defined as a sudden reduction in blood flow to a limb, resulting in cessation of blood flow and, therefore, cessation of the delivery of nutrients and oxygen to the tissues of the lower limb. Despite optimal treatment to restore blood flow to ischemic tissues, some patients may suffer from ischemia/reperfusion (I/R) syndrome, the most severe complication after a revascularization procedure used to restore blood flow. There are multiple molecular and cellular factors that are involved in each phase of ALI. This review focuses firstly on molecular and cellular factors of arterial thrombosis, highlighting the role of atherosclerotic plaques, smooth muscle cells (SMCs), and cytokine which may alter key components of the extracellular matrix (ECM). Then, molecular and cellular factors of arterial embolism will be discussed, highlighting the importance of thrombi composition. Molecular and cellular factors of ischemia/reperfusion syndrome are analyzed in depth, highlighting several important mechanisms related to tissue damage, such as inflammation, apoptosis, autophagy, necrosis, and necroptosis. Furthermore, local and general complications of ALI are discussed in the context of molecular alterations. Ultimately, the role of novel biomarkers and targeted therapies is discussed.

Clinical characteristics of extracorporeal cardiopulmonary resuscitation in China: a multicenter retrospective study

PURPOSE

Extracorporeal cardiopulmonary resuscitation (ECPR) might markedly increase the survival of selected patients with refractory cardiac arrest. But the application situation and indications remained unclear.

MATERIALS AND METHODS

We respectively reviwed all adult patients who underwent ECPR from January 2017 to March 2021. Patient characteristics, initiation and management of ECMO, complications, and outcomes were collected and compared between the survivors and nonsurvivors. LASSO regression was used to screen risk factors. Multivariate logistic regression was performed with several parameters screened by LASSO regression.

RESULTS

Data were reported from 42 ECMO centers covering 19 provinces of China. A total of 648 patients were included in the study, including 491 (75.8%) males. There were 11 ECPR centers in 2017, and the number increased to 42 in 2020. The number of patients received ECPR increased from 33 in 2017 to 274 in 2020, and the survival rate increased from 24.2% to 33.6%. Neurological complications, renal replacement therapy, epinephrine dosage after ECMO, recovery of spontaneous circulation before ECMO, lactate clearance and shockable rhythm were risk factors independently associated with outcomes of whole process. Sex, recovery of spontaneous circulation before ECMO, lactate, shockable rhythm and causes of arrest were pre-ECMO risk factors independently affecting outcomes.

CONCLUSIONS

From January 2017 to March 2021, the numbers of ECPR centers and cases in mainland China increased gradually over time, as well as the survival rate. Pre-ECMO risk factors, especially recovery of spontaneous circulation before ECMO, shockable rhythm and lactate, are as important as post-ECMO management,. Neurological complications are vital risk factors after ECMO that deserved close attention.

TRIAL REGISTRATION

NCT04158479, registered on 2019/11/08. https://clinicaltrials.gov/NCT04158479.

Association between physiotherapist sleep duration and working environment during the coronavirus disease 2019 pandemic in Japan: A secondary retrospective analysis study

Studies have reported that health care professionals experienced a lack of sleep during the coronavirus disease 2019 (COVID-19) pandemic and that such lack of sleep and working environment affect their performance. However, to the authors' knowledge, no study has yet investigated the relationship between sleep duration and working environment among Japanese physiotherapists during the COVID-19 pandemic. This study retrospectively investigated the sleep duration of physiotherapists directly providing physiotherapy to patients with COVID-19 within the red zone and analyzed the association between sleep duration and working environment using logistic regression analysis. Among the 565 physiotherapists studied, the average sleep duration was 6 (6-7) h, and 381 (67.4%) had an average sleep duration of ≤6 h. Less experienced physiotherapists were 1.03 times more likely to sleep ≤6 h, and those in charge of patients with COVID-19 as the supervisor ordered were 0.64 times more likely to sleep ≤6 h. Moreover, physiotherapists with a significant increase in the frequency of internal online meetings and those who had been providing physiotherapy to patients with COVID-19 for >6 months were 2.34 and 2.05 times more likely to sleep ≤6 h, respectively. During the COVID-19 pandemic in Japan, two-thirds of the physiotherapists directly providing physiotherapy to patients with COVID-19 slept less than the recommended duration. This study highlights the need for appropriate workload and work hour management for physiotherapists according to their experience and workload, as well as establishing a medical care system that includes work rotation to ensure that the recommended sleep duration is satisfied.

Clinical investigation for the mechanisms of anaphylactic symptoms in osteoarthritis patients after diclofenac etalhyaluronate administration

OBJECTIVE

This study was conducted to investigate the mechanisms of anaphylaxis in patients with osteoarthritis of the knee and hip after diclofenac etalhyaluronate [product name: JOYCLU® (JCL)] intra-articular injection and to determine the utility of tests to investigate the mechanism involved.

METHODS

In this observational study in Japan, patients aged ≥20 years with knee or hip osteoarthritis who received JCL intra-articular injection experienced anaphylactic symptoms considered related to JCL ('experienced patients') or did not experience allergic symptoms considered related to JCL ('non-experienced patients'). Basophil activation tests (BATs), specific immunoglobulin E (IgE) antibody testing by enzyme-linked immunosorbent assays (ELISAs) or immunochromatographic kit, and genome-wide association studies (GWASs) were conducted using patient blood and saliva.

RESULTS

Thirteen experienced patients and 14 non-experienced patients were tested. Seven experienced patients tested positive by BAT using diclofenac etalhyaluronate-containing test substances. Diclofenac-specific IgE antibodies were detected in four of seven BAT-positive patients but not in the non-experienced patients. Specific IgE antibody testing by immunochromatographic kit and genome-wide association study showed no clear results.

CONCLUSIONS

These findings suggest that anaphylaxis occurs after JCL administration via an IgE-mediated mechanism and that diclofenac etalhyaluronate may be involved in this mechanism. BAT and diclofenac -specific IgE enzyme-linked immunosorbent assay may be useful tests for investigating the mechanisms of anaphylactic reactions after JCL administration.

Consequences of a stay in the intensive care unit and outpatient follow-up care for chronic critically ill patients: A retrospective data analysis

BACKGROUND

Patients with chronic critical illness (CCI) represent a particularly vulnerable patient population with significant quality-of-life consequences and a need for follow-up care. Existing research on their quality-of-life trajectory and outpatient follow-up care is limited.

OBJECTIVES

The aim of this study was to (i) describe a quality improvement project focussing on patients with CCI in the Swiss setting; (ii) explain the consequences of an intensive care unit (ICU) stay for patients with CCI; and (iii) evaluate outpatient follow-up care for patients with CCI.

METHODS

This retrospective descriptive mixed-methods longitudinal study used routine data from outpatient follow-up care between October 2018 and June 2022. The pre-ICU data were collected retrospectively for the week before ICU admission (baseline); prospectively at 3, 6, and 12 months after ICU discharge; and during an outpatient follow-up care at 6 months. Its main outcomes were health-related quality of life (HRQOL). Patients with CCI were defined as those having a ICU stay longer than 7 days.

RESULTS

This study enrolled 227 patients with outpatient follow-up care, but only 77 were analysed at all four timepoints. Their EuroQol five-dimension five-level questionnaire-Visual Analogue Scale scores ranged from 0 to 100, with a median of 85 (interquartile range = 0-100) and a mean of 77.2 (standard deviation ± 23.52) before their ICU stay. Their scores had almost returned to the baseline 12 months after their ICU stay. While some reported existing restrictions in the individual HRQOL dimensions before their ICU stay, patients and their families appreciated the outpatient follow-up care including an ICU visit.

CONCLUSION

Patients with CCI have different HRQOL trajectories over time. Patients with CCI can have a good HRQOL despite their impairments; however, the HRQOL trajectories of many patients remain unclear. The focus must be on identifying the illness trajectories and on measuring and maintaining their long-term HRQOL.

Effectiveness of a hybrid emergency room system in the management of acute ischemic stroke: a single-center experience

Introduction

Hybrid emergency room systems (HERSs) have shown promise for the management of severe trauma by reducing mortality. However, the effectiveness of HERSs in the treatment of acute ischemic stroke (AIS) remains unclear. This study aimed to evaluate the impact of HERSs on treatment duration and neurological outcomes in patients with AIS undergoing endovascular therapy.

Materials and methods

This single-center retrospective study included 83 patients with AIS who were directly transported to our emergency department and underwent endovascular treatment between June 2017 and December 2023. Patients were divided into the HERS and conventional groups based on the utilization of HERSs. The primary outcome was the proportion of patients achieving a favorable neurological outcome (modified Rankin Scale score 0-2) at 30 days. The secondary outcomes included door-to-puncture and door-to-recanalization times. Univariate analysis was performed using the Mann-Whitney U test for continuous variables and the chi-squared test or Fisher's exact test for categorical variables, as appropriate.

Results

Of the 83 eligible patients, 50 (60.2%) were assigned to the HERS group and 33 (39.8%) to the conventional group. The median door-to-puncture time was significantly shorter in the HERS group than in the conventional group (99.5 vs. 131 min; p = 0.001). Similarly, the median door-to-recanalization time was significantly shorter in the HERS group (162.5 vs. 201.5 min, p = 0.018). Favorable neurological outcomes were achieved in 16/50 (32.0%) patients in the HERS group and 6/33 (18.2%) in the conventional group. The HERS and conventional groups showed no significant difference in the proportion of patients achieving favorable neurological outcomes (p = 0.21).

Conclusion

Implementation of the HERS significantly reduced the door-to-puncture and door-to-recanalization times in patients with AIS undergoing endovascular therapy. Despite these reductions in treatment duration, no significant improvement in neurological outcomes was observed. Further research is required to optimize patient selection and treatment strategies to maximize the benefits of the HERS in AIS management.

Evaluation of the Pedagogical Impact of "Traum'Cast" Podcast: A Pilot Study Based on Metacognition

INTRODUCTION

With the evolution of educational tools, the French Military medical service has created a podcast program, Traum'Cast, about the principles of war medicine, accessible online for free.

METHOD

Our objective was to measure the learning effect of the Traum'Cast program's first episode. A non-randomized pilot trial between July and December 2021 included 80 health care providers: 40 in the video podcast group compared to 40 in a group reading a pdf file providing the same information. Using a 10 MCQs, we evaluated knowledge acquisition before, just after, and 2 weeks after the intervention. It was measured using metacognition tools based on confidence marking (number of correct answers, score weighted by certainty level, and realism).

RESULTS

Knowledge acquisition was better in the podcast group than in the pdf file group immediately after the intervention (correct answers: 9.0 [9.0-10.0] vs 9.0 [7.8-9.0], P = 0.015; weighted score: 177.0 [159.0-198.0] vs 160.0 [129.5-176.5], P = 0.020). This difference was persistent 2 weeks after (weighted score: 127.5 [101.8-145.2] vs 105.5 [74.2-128.5], P = 0.023).

CONCLUSION

This podcast is an innovative teaching tool which has proven to strengthen the knowledge of the principles of war medicine.

Case report: Near-fatal hypermagnesemia resulting from the use of Epsom salts in a patient with normal renal function

Hypermagnesemia commonly occurs in patients with renal dysfunction. Diagnosing hypermagnesemia represents a challenge due to its rarity and the absence of routine monitoring of magnesium levels. Furthermore, the lack of awareness among clinicians regarding this uncommon condition frequently leads to delayed diagnoses. Few patients survive with a serum magnesium level exceeding 7 mmol/L. This article presents a case study of near-fatal hypermagnesemia resulting from the oral administration of Epsom salts in a patient with normal renal function. A 60-year-old female presented to the gastroenterology department on Oct. 6, 2023, with a 3-day history of black stools. She underwent subtotal gastrectomy in 2005 and has a stable history of nephrotic syndrome. To investigate the cause of her bleeding, electronic gastroscopy and colonoscopy were scheduled for Oct. 11, 2023. She experienced a sudden loss of consciousness 30 min after the ingestion of Epsom salts. The attending physician suspected a severe magnesium poisoning. She was promptly administered calcium gluconate, underwent tracheal intubation with ambu bag ventilation, and received early continuous renal replacement therapy (CRRT). Swift diagnosis and CRRT contributed to a reduction in her serum magnesium levels from an initial 8.71 mmol/L to 1.35 mmol/L, leading to a remarkable improvement in the toxic symptoms associated with hypermagnesemia. Subsequently, she was managed in the gastroenterology department, with gastroscopy revealing bleeding from the gastrointestinal anastomotic ulcer. Following conservative treatments including acid suppression, stomach protection, and hemostasis, her symptoms improved, and she was successfully discharged. This study aims to alert clinicians to the possibility of hypermagnesemia in individuals with normal renal function. Physicians should exercise caution when prescribing Epsom salts to patients with underlying gastrointestinal conditions. If necessary, alternative drug therapies may be considered to mitigate the risk of hypermagnesemia. Timely intervention is pivotal in averting life-threatening complications linked to hypermagnesemia.

Falls in older adults hospitalized in tertiary centers in Colombia. Clinical description and complications

OBJECTIVE

The incidence of falls in elderly patients in the hospital environment is three times higher than that in the community. The aim was to determine the characteristics of patients who suffered in-hospital falls and their complications.

METHODS

This was a cross-sectional study with patients older than 64 years of age, admitted between 2018 and 2020 to four clinics in Colombia who presented a fall during their stay. Clinical data, reasons for the fall, complications and use of drugs with a known risk for causing falls and with an anticholinergic load were reviewed.

RESULTS

A total of 249 patients were included. The mean age was 77.5 ± 7.4 years, and there was a predominance of males (63.9%). The patients were hospitalized mainly for community-acquired pneumonia (12.4%) and heart failure (10.4%). Falls occurred most frequently in hospitalization wards (77.1%) and emergency departments (20.9%). Falls were related to standing alone (34.4%) and on the way to the bathroom (28.9%), with 40.6% (n = 102) of falls resulting in trauma, especially to the head (27.7%); the incidence of fractures was low (3.2%). Ninety-two percent of patients had polypharmacy (≥5 drugs), 88.0% received psychotropic drugs, and 37.3% received drugs with an anticholinergic load ≥3 points.

CONCLUSIONS

Hospitalized adults over 65 years of age suffered falls, mainly in hospitalization wards and emergency departments, especially during the process of solitary ambulation. Most had received psychotropic drugs and medications with a high anticholinergic load. These results suggest that it is necessary to improve risk prevention strategies for falls in this population.

Associations between COVID-19 therapies and outcomes in rural and urban America: A multisite, temporal analysis from the Alpha to Omicron SARS-CoV-2 variants

PURPOSE

To investigate the enduring disparities in adverse COVID-19 events between urban and rural communities in the United States, focusing on the effects of SARS-CoV-2 vaccination and therapeutic advances on patient outcomes.

METHODS

Using National COVID Cohort Collaborative (N3C) data from 2021 to 2023, this retrospective cohort study examined COVID-19 hospitalization, inpatient death, and other adverse events. Populations were categorized into urban, urban-adjacent rural (UAR), and nonurban-adjacent rural (NAR). Adjustments included demographics, variant-dominant waves, comorbidities, region, and SARS-CoV-2 treatment and vaccination. Statistical methods included Kaplan-Meier survival estimates, multivariable logistic, and Cox regression.

FINDINGS

The study included 3,018,646 patients, with rural residents constituting 506,204. These rural dwellers were older, had more comorbidities, and were less vaccinated than their urban counterparts. Adjusted analyses revealed higher hospitalization odds in UAR and NAR (aOR 1.07 [1.05-1.08] and 1.06 [1.03-1.08]), greater inpatient death hazard (aHR 1.30 [1.26-1.35] UAR and 1.37 [1.30-1.45] NAR), and greater risk of other adverse events compared to urban dwellers. Delta increased, while Omicron decreased, inpatient adverse events relative to pre-Delta, with rural disparities persisting throughout. Treatment effectiveness and vaccination were similarly protective across all cohorts, but dexamethasone post-ventilation was effective only in urban areas. Nirmatrelvir/ritonavir and molnupiravir better protected rural residents against hospitalization.

CONCLUSIONS

Despite advancements in treatment and vaccinations, disparities in adverse COVID-19 outcomes persist between urban and rural communities. The effectiveness of some therapeutic agents appears to vary based on rurality, suggesting a nuanced relationship between treatment and geographic location while highlighting the need for targeted rural health care strategies.

Feeble, fallen, and forgetting: association of cognitive impairment and falls on outcomes of major intra-abdominal surgeries in older adults

BACKGROUND

Both cognitive impairment/dementia (CID) and falls occur more commonly in older adults than in younger patients. This study aimed to analyze the association of a history of CID or falls with the postoperative outcomes of older adults undergoing major intra-abdominal surgeries on a national level.

METHODS

We retrospectively analyzed the American College of Surgeons-National Surgical Quality Improvement Program 2022 Participant Use Data File. Our primary outcome was postoperative mortality. Statistical analysis was performed using the Chi-square test and multivariate regression analysis.

RESULTS

On multivariable regression analyses, a history of both CID (odds ratio [OR] = 1.9; CI: 1.5-2.5; P < .01) and a fall (OR = 1.8; CI: 1.4-2.3; P < .01) were independently associated with higher adjusted odds of mortality. History of CID or falls was also a predictor of overall complications, major complications, and discharge to a care facility.

CONCLUSION

A history of CID or falls in older adults before major intra-abdominal surgeries was associated with a high risk of postoperative mortality and morbidity. Further studies are required to establish the causal relation of these factors and the steps to mitigate the risk of associated adverse outcomes.

Baricitinib and Pulse Steroids Combination Treatment in Hyperinflammatory COVID-19: A Rheumatological Approach in the Intensive Care Unit

Hyperinflammatory Coronavirus disease 2019 (COVID-19) and rapidly-progressive interstitial lung diseases (RP-ILD) secondary to inflammatory myopathies (IIM) present important similarities. These data support the use of anti-rheumatic drugs for the treatment of COVID-19. The aim of this study was to compare the efficacy of combining baricitinib and pulse steroids with the Standard of Care (SoC) for the treatment of critically ill COVID-19 patients. We retrospectively enrolled consecutive patients admitted to the Intensive Care Unit (ICU) with COVID-19-pneumonia. Patients treated with SoC (dexamethasone plus remdesivir) were compared to patients treated with baricitinib plus 6-methylprednisolone pulses (Rheuma-group). We enrolled 246 patients: 104/246 in the SoC and 142/246 in the Rheuma-group. All patients presented laboratory findings suggestive of hyperinflammatory response. Sixty-four patients (26.1%) died during ICU hospitalization. The mortality rate in the Rheuma-group was significantly lower than in the SoC-group (15.5 vs. 40.4%, p < 0.001). Compared to the SoC-group, patients in the Rheuma-group presented significantly lower inflammatory biomarker levels after one week of treatment. Higher ferritin levels after one week of treatment were strongly associated with mortality (p < 0.001). In this large real-life COVID-19 cohort, baricitinib and pulse steroids led to a significant reduction in mortality, paralleled by a prompt reduction in inflammatory biomarkers. Our experience supports the similarities between hyperinflammatory COVID-19 and the IIM-associated RP-ILD.

Preoperative risk factors for 90-day postoperative mortality outcome in patients with non-occlusive mesenteric ischemia

PURPOSE

The mortality rate for non-occlusive mesenteric ischemia remains high even after patients survive the acute postoperative period with tremendous treatment efforts, including emergency surgery, which is challenging. The aim of this study was to explore the preoperative risk factors for 90-day postoperative mortality in patients with non-occlusive mesenteric ischemia.

METHODS

This single-center, retrospective cohort study included patients diagnosed with non-occlusive mesenteric ischemia who underwent emergency surgery between August 2014 and January 2023. All patients were divided into survival-to-discharge and mortality outcome groups at the 90-day postoperative follow-up. Preoperative factors, including comorbidities, preoperative status of vital signs and consciousness, blood gas analysis, blood test results, and computed tomography, were compared between the two groups.

RESULTS

Twenty patients were eligible, and 90-day mortality was observed in 10 patients (50%). The mortality outcome group had significantly lower HCO3- (20.9 vs. 14.6, p = 0.006) and higher lactate (4.4 vs. 9.4, p = 0.023) levels than did the survival outcome group. The median postoperative time to death was 19 [2-69] days, and five patients (50%) died after postoperative day 30, mainly because hemodialysis was discontinued because of hemodynamic instability in patients requiring hemodialysis.

CONCLUSION

Low preoperative HCO3- and high lactate levels may be preoperative risk factors for 90-day postoperative mortality in patients with non-occlusive mesenteric ischemia. However, patients on hemodialysis die from discontinuing hemodialysis even after surviving the acute postoperative phase. Therefore, indications for emergency surgery in patients with risk factors for postoperative mortality should be carefully determined.