National Survey and consensus document on dosing strategies for beta-lactam antibiotics against multidrug-resistant gram-negative bacilli (MDR-GNB) in critically ill patients undergoing extracorporeal life support techniques: The DOSEBL study protocol

INTRODUCTION

Infections caused by multidrug-resistant gram-negative bacilli (MDR-GNB) in critically ill patients present a challenge for timely and appropriate antibiotic treatment. This is particularly important in patients undergoing extracorporeal life support techniques such as renal replacement therapy and extracorporeal membrane oxygenation. These techniques can introduce additional pharmacokinetic alterations, potentially leading to suboptimal exposure to antibiotics. This study aims to outline dosing strategies and therapeutic drug monitoring protocols for new β-lactam antibiotics effective against MDR-GNB in critically ill patients undergoing extracorporeal life support techniques at a national level. Additionally, the study seeks to develop a consensus document, based on available evidence.

METHODS

The project will comprise two main phases: I) A national survey, and II) the development of a consensus document. This consensus document, undertaken according to ACCORD guidelines, will encompass: a) establishment of a multidisciplinary panel of experts, b) prospective registration of the consensus, c) evidence synthesis, d) modified Delphi rounds. The antimicrobials to be included will be: meropenem, ceftazidime/avibactam, ceftolozane/tazobactam, cefiderocol, meropenem/vaborbactam, imipenem/relebactam, and aztreonam. Extracorporeal life support techniques will include continuous renal replacement therapy, conventional intermittent hemodialysis, and extracorporeal membrane oxygenation.

DISCUSSION

The availability of extracorporeal life support techniques has expanded significantly in recent years, alongside a rise in the prevalence of infections caused by multidrug-resistant gram-negative bacilli (MDR-GNB). There is a need to develop evidence-based tools of high quality to standardize dosing and monitoring strategies for new β-lactam antibiotics.

Descending necrotizing mediastinitis complicating deep neck abscesses: clinical features and prognostic assessment in 45 ICU patients

PURPOSE

To describe the clinical features and identify mortality risk factors in descending necrotizing mediastinitis (DNM) complicating deep neck abscesses (DNA) among patients admitted to the ICU.

METHODS

A retrospective analysis was conducted on consecutive patients admitted to the ICU of a tertiary care public hospital. Data were collected from July 2017 to July 2024. A bivariate analysis of variables, along with a multiple logistic regression model, were performed to identify mortality risk factors.

RESULTS

Forty-five patients with DNA complicated by DNM were admitted to the ICU, of whom 29 (58%) were men. The mean age was 49.8 ± 14 years. All underwent emergency neck and mediastinum debridement. Forty-one (91%) were admitted directly from the operating room. All DNAs were of odontogenic origin. In 36 patients (80%), the mediastinal infection extended below the tracheal carina. Thirty-nine patients (86.6%) required mechanical ventilation, and 25 (55.5%) presented with septic shock. The in-hospital mortality rate was 33.3%. Risk factors for mortality in the bivariate analysis included the total SOFA (Sequential Organ Failure Assessment) score, individual SOFA components (respiratory, hematologic, and cardiovascular), SAPS-3 (Simplified Acute Physiology Score-3), platelet-to-lymphocyte ratio, and monocyte-to-lymphocyte ratio. In the multivariate analysis, the number of neck surgical debridements performed during ICU stay and the SOFA respiratory component were independent predictors of mortality.

CONCLUSIONS

DNM complicating a DNA is a severe condition frequently associated with septic shock and multi-organ failure. Impaired oxygenation at admission and the number of neck wound debridements significantly influenced patient outcomes.

Risk factors and prevalence of medical device-related pressure injuries in pediatric intensive care

OBJECTIVES

This study aimed to determine the incidence of pressure injuries (PI) in patients connected to medical devices during their treatment in the pediatric intensive care unit (PICU), the risk factors, and the most accurate scale that assesses PI.

METHODS

A cross-sectional study adhering to STROBE guidelines. It was carried out with 70 children connected to medical devices during their treatment in the PICU between 12.01.2023 and 06.30.2024. The PI development risk statuses of the patients associated with medical devices were evaluated using the Braden Q Scale, the BUCH Scale, the Glamorgan Pediatric PI Risk Assessment Scale, and an Injury Monitoring Form.

RESULTS

The incidence of medical device-related pressure injuries (MDPI) in the PICU was 12.8 %. MDPI developed the most frequently in the nasal and oral regions, and 61.5 % of these injuries were Stage 1. The equipment with the highest rates of contribution to PI included nasogastric tubes, orogastric feeding equipment, and oral intubation tubes. The Braden Q, BUCH, and Glamorgan Scales had AUC values of 0.91, 0.83, and 0.80, sensitivity values of 77 %, 77 %, and 66 %, and specificity values of 82 %, 69 %, and 62 %, respectively.

CONCLUSIONS

The results of this study highlight that medical devices used to support the recovery of critically ill children in the PICU pose a significant risk for PI development.

IMPLICATIONS FOR CLINICAL PRACTICE

Determining incidence and risk factors is important to prevent PI. Appropriate protocols, interventions, and strategies can be developed to manage the identified MDPI risk factors.

Have the recent advancements in wound repair and scar management technology improved the quality of life in burn patients?

BACKGROUND

The negative physical and psychosocial impact of scars, in particular burn scars, has been well documented. Altered personal appearance together with impaired function related to pain, heat intolerance, and contracture formation may last a lifetime and eventually can lead to low self-esteem and poor social and psychological adjustments. Though most patients recover within the first years and many report generally good life satisfaction and moderate quality of life (QoL), some severely burned patients continue to report impaired QoL almost 10 years after injury. It is repeatedly mentioned in the literature that patients' QoL and health-related quality of life (HRQoL) can be improved by improving wound healing and burn scar quality. Determining whether advances in burn wound healing and scar management modalities are positively impacting the lives of surviving patients is the aim of this review.

METHODS

A systematic literature review was used to identify studies measuring QoL of patients surviving severe burn injuries following various interventions to improve burn wound healing and scar quality.

RESULTS

A limited number of studies was identified. Given the limited available data, a narrative review approach including qualitative studies and reviews in addition to identifying common themes, trends, and gaps in the existing literature was deemed more appropriate for a comprehensive analysis.

CONCLUSION

The assumption that progress made in recent decades to improve burn wound healing and scar quality would improve QoL remains largely hypothetical. Except for functional release of burn scar contractures, improved scar aesthetic quality does not necessarily translate into improved QoL of surviving patients. Well-designed comparative studies are largely lacking.

Comparison of Risk Assessment Tools' Prediction of Outcomes for Penetrating Trauma

INTRODUCTION

The Trauma and Injury Severity Score (TRISS) uses anatomic and/or physiologic variables to predict mortality; however, Injury Severity Score is less reliable for penetrating trauma. National Surgical Quality Improvement Program Surgical Risk Calculator (NSQIP-SRC) and American Society of Anesthesiologists Physical Status (ASA-PS) include functional status and comorbidities. This study evaluates the accuracy of these tools in predicting mortality, length of stay (LOS), and complications for operative penetrating trauma.

METHODS

Adult penetrating trauma patients (≥18 y) who underwent surgery within 24 h of admission were included in this subgroup analysis of a prospective observational study at four trauma centers. The following three scoring models were compared: NSQIP-SRC, TRISS, and ASA-PS. Brier scores and area under the receiver-operating characteristic curve were used to compare mortality prediction. LOS prediction was assessed with linear regression and complications were evaluated with negative binomial regression. Likelihood ratio (LR) test was used to assess model fit.

RESULTS

Of 329 penetrating trauma patients, 13 (3.9%) died. The median LOS was 4 d (interquartile range 2-9), and median number of complications was zero (interquartile range 0-1). TRISS better predicted mortality than NSQIP-SRC or ASA-PS on Brier score (0.02 versus 0.03 versus 0.03) but all had similar area under the receiver-operating characteristic curve (0.93 versus 0.93 versus 0.91, P = 0.26). NSQIP-SRC and ASA-PS better predicted LOS on adjusted R2 (14.4% versus 14.1% versus 1.6%) and LR showed no difference between these two tools (P = 0.16). NSQIP-SRC best predicted complications compared to TRISS and ASA-PS (Pseudo R2: 10.3% versus 3.8% versus 5.5%; LR: P = 0.003).

CONCLUSIONS

For penetrating trauma, all three models were similarly excellent at predicting mortality. NSQIP-SRC and ASA-PS better predicted LOS and NSQIP-SRC best predicted complications, suggesting these are better tools for prognostication of outcomes for penetrating trauma.

Analgosedation and delirium practices in critically ill patients in the Pan-American and Iberian setting, and factors associated with oversedation after the COVID-19 pandemic: Results from the PANDEMIC study

Oversedation has adverse effects on critically ill patients. The Analgosedation and Delirium Committee of the FEPIMCTI (Pan-American and Iberian Federation of Critical Care Medicine and Intensive Care) conducted a cross-sectional study through a survey addressed to ICU physicians: PANDEMIC (Pan-American and Iberian Study on the Management of Analgosedation and Delirium in Critical Care [fepImCti]). HYPOTHESIS: Worsening of these practices in the course of the pandemic and that continued afterwards, with further oversedation. OBJECTIVES: Perception of analgosedation and delirium practices in Pan-American and Iberian ICUs before, during and after the COVID-19 pandemic, and factors associated with persistent oversedation after the pandemic. Of the 1008 respondents, 25% perceived oversedation after the pandemic (95%CI 22.4-27.8). This perception was higher in South America (35.8%, P < .001). Main risk factor: habit acquired during the pandemic (adjusted OR [aOR] 3.16, 95%CI 2.24-4.45, P < .001). Main protective factor: delirium monitoring before the pandemic (aOR 0.70, 95%CI 0.50-0.98, P = .038). The factors identified in this study provide a basis for targeting future interventions.

Insights into Congenital Body Stalk Anomaly Coupled with Placenta Accreta Conditions: A Case Report

BACKGROUND Body stalk anomaly is a rare abdominal wall defect thought to be a consequence of abnormalities in the development of cephalic, caudal, and lateral embryonic folding and defect in closure of the body wall during embryogenesis. Placenta accreta spectrum (PAS) is a general term frequently used to encompass accreta, increta, and percreta conditions. This report describes a distinct pregnancy with a body stalk abnormality and PAS. CASE REPORT A 34-year-old woman, gravida 2 para 1, with no previous abortions, was referred to the Maternal-Fetal Medicine Unit for further investigation of omphalocele at 29 weeks of gestation. Although the defect was not suspected during the first trimester scan, subsequent obstetric ultrasounds revealed a severe abdominal wall defect, kyphoscoliosis, a very rudimentary umbilical cord, and limb defects. Ultrasound examination of the placenta showed increased vascularity at the placental bed and loss of the retroplacental-myometrial radiolucent interface, leading to diagnosis of suspected body stalk anomaly, with PAS. Cesarean delivery was performed at 30 weeks, with plan for conservative treatment for PAS, including uterine-sparing surgery. Baby was born weighing 800 g and measuring 25 cm in length, with an APGAR score of 1-1. Clinical examination confirmed a very short umbilical cord and severe abdominal wall and limb defects. However, due to significant hemorrhage during surgical procedure, cesarean hysterectomy was done. CONCLUSIONS The management of body stalk anomaly with PAS is challenging. Preconception counseling is important to detect abnormalities earlier, and a multidisciplinary care team is needed to create patients' treatment plans. This congenital defect is invariably fatal.

Humanization strategies in pediatric intensive care: A scoping review

BACKGROUND

The international HU-CI project advocates eight strategic strands for the humanization of intensive care units. Despite of adult ICUs have received attention to promote humanization of care, in the paediatric context, the humanization of care continues to receive limited attention, with limited data on paediatric structures and humanization patterns lacking integration into practice.

OBJECTIVES

Identify available evidence related to humanization concepts according to the theoretical framework of the HU-CI Project and understand the implementations in the field of paediatric intensive care units.

METHOD

A scoping review was conducted through a literature search in PubMed and CINAHL. Studies addressing concepts or elements related to the strategic lines of the HU-CI framework within the context of paediatric intensive care units were included. The perspective of patients, families, and frontline healthcare professionals was considered, using quantitative, qualitative, and mixed methods approaches. Data analysis followed a narrative approach, categorically synthesised according to the strategic lines of the HU-CI framework in paediatric intensive care units.

RESULTS

A total of 41 articles were included. Within the eight action lines of action of the HU-CI framework, end-of-life care and communication predominated over flexible schedules, family presence and participation in care, patient well-being, professional care, post-ICU syndrome and humanised infrastructure.

CONCLUSIONS

The analysed action lines suggest the need for development and improvement through further research to facilitate their full integration into the practice of paediatric intensive care units.

Nociceptive and non-nociceptive pain in critical care patients after cardiac surgery

AIM

To assess pain intensity during nociceptive (endotracheal suctioning) and non-nociceptive (body temperature measurement) procedures in critically ill patients after cardiac surgery.

METHODS

A descriptive and cross-sectional design was carried out. The study sample consisted of 60 critically ill patients. The study used the Critical Care Pain Observation Scale, the Behavioural Pain Scale, the Ramsey Sedation Scale and Physiological Parameter Form for data collection. Pain was assessed before, during, and 20 min after endotracheal suctioning and body temperature measurement in the study.

RESULTS

The pain scores were found to be statistically significant differences during endotracheal suctioning and body temperature measurement (p < 0.001). Pain scores were found to be higher during endotracheal suctioning, which is a nociceptive procedure (p < 0.05). Systolic and diastolic blood pressure, heart rate scores were also determined to be statistically higher during endotracheal suctioning (p < 0.05).

CONCLUSION

Pain scores and physiological parameters were found to be higher during endotracheal suctioning, a procedure known to be nociceptive. Critical care nurses are recommended to follow pain assessment protocols.

Morbidity prediction in conservatively managed rib fracture patients

PURPOSE

Rib fractures, common in blunt chest trauma, affect 10% of trauma patients and are linked to increased pulmonary morbidity and mortality. This study applies machine learning to identify predictors of complications in conservatively managed rib fracture patients.

METHODS

Data from the 2013-2021 American College of Surgeons' Trauma Quality Improvement Program included adults (≥ 18 years) with isolated thoracic injury from blunt trauma and conservatively managed rib fractures. Variables included demographics, comorbidities, injury severity, injury patterns, admission vitals, and complications. The permutation importance method identified top predictors of in-hospital complications.

RESULTS

Of 321,355 rib fracture patients, 183,303 (57.0%) had isolated rib fractures. The five primary predictors of complications in all rib fracture patients were age, Glasgow Coma Scale (GCS) on admission, Revised Cardiac Risk Index (RCRI), chronic obstructive pulmonary disease (COPD), and alcohol use disorder. For isolated rib fracture patients, the same predictors applied but in the order: age, RCRI, GCS, COPD, and alcohol use disorder. A logistic regression model using these predictors showed acceptable discriminative capacity for complications in the full cohort [AUC (95% CI): 0.72 (0.71-0.72)] and isolated rib fracture patients [AUC (95% CI): 0.72 (0.71-0.73)].

CONCLUSION

Cardiovascular risk, age, and level of consciousness on admission are key predictors of complications in conservatively managed rib fracture patients. Though complication rates remain low overall, elderly patients with multiple cardiovascular risk factors face a heightened risk of deterioration.

Emergency Department Clinical Quality Registries: A Scoping Review

BACKGROUND

Emergency departments (ED) are vital within the health system, often representing the first hospital contact for patients who are undifferentiated and may be critically ill. Although advancements in digital technology and increasing use of electronic medical records in health systems have led to the dramatic growth of large data sets, the presence of ED clinical registries to measure quality of care in the literature is currently unknown.

OBJECTIVES

Our scoping review aims to investigate the extent of emergency department clinical registries reported in peer-reviewed literature.

METHODS

We conducted a scoping review of ED registries in accordance with the PRISMA-ScR checklist. Searches were undertaken in PUBMED, EMBASE, and SCOPUS. Studies were included if they described a clinical registry with a focus on the ED.

RESULTS

We identified 60 manuscripts with 27 identified as primary registries (6 had a general scope, 21 were condition or population specific). The remaining 33 papers were investigational reports sourced from the identified primary registries. Funding sources were identified for some registries: three by research grants, two by medical colleges, five by government organizations or initiatives, two by pharmaceutical companies, and three by research institutes. No funding information was provided in 12 studies. The reported registry periods ranged from 31 days to 4018 days (median 365 days, IQR 181-1309 days). A grey literature search revealed that six registries were ongoing.

CONCLUSIONS

Internationally, there appears to be a wide degree of heterogeneity with primary ED registry publications and secondary publications. Having a standardized approach to ED registries is needed. Integrating ED registries with a learning health system model will enable clinicians to serve their community proactively and with a focus on quality, rather than the current safety-focused approach.

Quality improvement program for the severely injured

Over recent decades, advancements in trauma care have significantly reduced mortality rates among severely injured patients. These improvements are largely attributable to the establishment of trauma care systems, including prehospital management protocols and the creation of trauma centres with immediate surgical team availability. However, patient outcomes continue to vary, reflecting differences in the quality of trauma care influenced by organisational models and local practices. To address this, governments and scientific organisations have underscored the importance of evaluating care quality at local, national, and international levels. This chapter explores strategies for assessing quality of trauma care, establishing reliable quality indicators (QIs), and standardising auditing processes to guide improvements in patient outcomes and system performance.

Identification of pandemic ST147, ESBL-type β-lactamases, carbapenemases, and virulence factors in Klebsiella pneumoniae isolated from southern Peru

Multidrug-resistant Klebsiella pneumoniae (MDR K. pneumoniae) is a significant pathogen associated with nosocomial infections, often leading to high morbidity and mortality. This resistance is largely due to the efficient horizontal transfer of mobile genetic elements such as plasmids, which carry resistance genes and virulence factors. These elements contribute to the production of extended-spectrum β-lactamases (ESBL) and carbapenemases, which further complicates treatment. Despite the high prevalence of MDR K. pneumoniae in Peruvian hospitals, the genomic characterization of these strains remains limited. This study investigated the phenotypic and molecular identification of extended-spectrum β-lactamases (ESBLs), carbapenemases, and virulence factors in 91 MDR K. pneumoniae strains collected from three hospitals between 2022 and 2023. Phenotypic detection of ESBLs was performed using the Jarlier method, while carbapenemases were identified via double-disk synergy testing with boronic acid, EDTA, and Carba NP test. The positive isolates were further analyzed for resistance genes (blaCTX-M, blaTEM, blaSHV, blaKPC, blaNDM, blaIMP, and blaVIM). Four isolates were subjected to whole-genome sequencing (WGS) for further characterization. All multidrug-resistant K. pneumoniae strains (100%) were ESBL-positive, with 14.3% producing carbapenemases, primarily KPC-type and metallo-β-lactamases (MBLs). The virulence factor analyses revealed that only 7.7% exhibited hypermucoviscosity. Protease activity was detected in 19.8% of the strains, and lipase activity in 1.1%. Regarding biofilm formation, 85.7% of the strains showed moderate adherence. Molecular analysis identified ESBL (blaCTX-M, 78%; blaTEM, 71.4%; blaSHV, 82.4%) and carbapenemase genes (blaKPC 7.7%, blaNDM 4.4%). Genomic analysis revealed various antimicrobial resistance mechanisms, including porin-coding gene mutations, aminoglycoside resistance linked to fluoroquinolone resistance, and multidrug efflux pump regulators. Sequence typing has identified high-risk clones (ST147, ST629, and ST37) associated with hospital outbreaks globally. These findings underscore the considerable concern of MDR and hypervirulent K. pneumoniae in Peruvian hospitals. These findings emphasize the pressing need for sustained genomic surveillance, enhanced infection control measures, and strategies to address the expanding problem of MDR K. pneumoniae.

Experience with ECMO therapy for acute respiratory distress syndrome treatment throughout the COVID-19 pandemic

OBJECTIVE

To analyze our experience with extracorporeal membrane oxygenation (ECMO) therapy for acute respiratory distress syndrome (ARDS) treatment during the COVID-19 pandemic.

DESIGN

Retrospective, observational, single center study.

SETTING

Third-level hospital in Spain.

PATIENTS

Adult patients with COVID-19 ARDS treated with an ECMO system in our center between March 2020 and March 2023.

INTERVENTIONS

Retrospective collection of variables during hospital admission and follow-up.

MAIN VARIABLES OF INTEREST

Demographic variables, clinical history, variables related to ECMO therapy, COVID-19 wave number, in-hospital mortality, adverse events, ICU and hospital length of stay, and functional status at follow-up were collected.

RESULTS

Eighty-one patients were included. Of these, 61 patients (75%) died during hospitalization. Patients who died were older and had more comorbidities. During the second, third, and sixth waves, mortality was higher. In the multivariate analysis, the only independent predictor of mortality was age (OR 1.24 95% CI (1.027-1.5, P = 0.025). After discharge, 40% of patients had difficulties returning to normal life due to respiratory failure requiring oxygen and arthropathies.

CONCLUSION

In-hospital mortality increased during the pandemic. Older age was the only independent predictor of mortality. After discharge, no deaths were recorded during the first 18 months of follow-up, although 40% of surviving patients had respiratory and motor sequelae making it difficult for them to return to a normal life.

Nephrotic syndrome complicated with disseminated Nocardia sepsis: a case report and literature review

We present a patient diagnosed with nephrotic syndrome and disseminated Nocardia sepsis who was successfully treated with a combination of antibiotics and supportive care, including extracorporeal membrane oxygenation (ECMO). In addition, we performed a literature review of similar cases to provide valuable guidance for future management of cases. The present case demonstrates that ECMO should be included in the comprehensive treatment strategy for disseminated Nocardia sepsis in a patient with nephrotic syndrome. In the present case, Nocardia infection occurred during prolonged steroid and immunosuppressive therapy for nephrotic syndrome, accompanied by septic shock, respiratory failure, multiple organ dysfunction, ventilator-associated pneumonia, catheter-associated bloodstream infection with multidrug-resistant bacteria potentially due to ECMO, and hemopneumothorax. The patient received invasive ventilation, ECMO, hemoperfusion for cytokine removal, and thoracoscopic drainage, which effectively eliminated symptoms to achieve complete recovery. ECMO was applied as a life-support intervention to manage severe respiratory failure and septic shock secondary to disseminated Nocardia sepsis. This approach provides adequate infection control and stabilization of organ functions. The findings suggested that a combination of 2 to 3 antibiotics, including trimethoprim-sulfamethoxazole, imipenem, and linezolid, alleviated the severe Nocardia infections. Therefore, ECMO may serve as a supportive intervention in severe infections but requires careful risk-benefit analysis. In such cases, strict monitoring is required to prevent the occurrence of bloodstream infections, particularly multidrug-resistant bacteria, during ECMO cannulas or circuits.

Comparative analysis of patient and family satisfaction in Spanish Intensive Care Units: A cross-sectional study of the impact of diagnosis

BACKGROUND

Analysing relatives and patients experiences and satisfaction can highlight areas for improving Intensive Care Units (ICUs) care. Patients and families may differ about satisfaction and experience, depending on the diagnosis and procedures. We aimed to compare the experience and satisfaction of patients according to diagnosis, severity, and the procedures received, and also between relatives and patients.

METHODS

Prospective analysis of voluntary responses to the FS (Family Satisfaction)- ICU 24 R questionnaire from surviving ICU patients and their relatives (January-April 2023) in four Spanish hospitals, according to diagnostic groups. Responses were scored on a Likert scale (0: worst score; 100: best score), and means and standard deviations were compared.

RESULTS

185 responses were analysed, mostly acute cardiac pathology patients (91, 50.83%), followed by septic shock patients (22.9%). Patients rated the team performance higher than their relatives (98.79 ± 5.37 vs 89.68 ± 18.43; p < 0.0001), also symptom management such as pain (95.62 ± 9.52 vs 89.64 ± 17.24; p = 0.0001, and dyspnoea (94.23 ± 12.27 vs 88.09 ± 17.87; p = <0.001), the information process (91.50 ± 13.43 vs 83.17 ± 21.00; p < 0.001), and decision-making (80.38 ± 13.60 vs 65.84 ± 23.60; p < 0.001). Patients found visits to be scarce (43.75 ± 20.79), although their families were satisfied with their involvement in care (85.49 ± 19.64). Patients with sepsis and septic shock rated pain management the lowest compared to other diagnostic groups (sepsis/septic shock 89.58 ± 12.5 vs 98.61 ± 5.89; p < 0.001).

CONCLUSIONS

Open visiting policies and enhancing the protocols for conscious sedation/analgesia in invasive procedures are opportunities to improve the satisfaction and experience of ICU patients and their families.

Use of Oligomeric Formulas in Malabsorption: A Delphi Study and Consensus

Background: Malabsorption syndrome is characterized by chronic diarrhea, abdominal distension, and malnutrition, thereby complicating its diagnosis and treatment. Oligomeric enteral formulas, designed to facilitate absorption in patients with compromised bowel function, have shown clinical efficacy, though their implementation lacks standardization due to the lack of uniform protocols. Objective: To establish a multidisciplinary consensus on the use of oligomeric formulas in patients with malabsorption using a Delphi methodology. Material and Method: A Delphi study was conducted with 156 specialists in endocrinology, gastroenterology, oncology, and internal medicine. Two rounds of structured surveys assessed clinical practices, associated symptoms, and the use of oligomeric enteral formulas. Data were analyzed using descriptive statistics and non-parametric tests, defining consensus with a median of ≥7 and an interquartile range of ≤3. Likewise, a Median (MED) score of ≤3 was considered as a consensus to reject the statement, while an Interquartile range (IQR) of ≥4 or a MED of 4-6 was considered as no agreement. These statements were reviewed and included in the second round. Results: Screening for malnutrition is widely supported (79%), but only 38% of participants reported having specific management protocols. Symptoms such as abdominal distension, abdominal pain, and diarrhea were identified as key predictors of intolerance to polymeric formulas, establishing oligomeric enteral formulas as first choice in these cases. In addition, the effectiveness of an approach that progresses from oligomeric to polymeric enteral formulas once symptoms have stabilized was highlighted. The need for standardized protocols was recognized as a priority to guide nutritional assessment and treatment in patients with malabsorption. Conclusions: This consensus reinforces the importance of implementing specific clinical protocols for the nutritional management of malabsorption, including the initial use of oligomeric enteral formulas in patients with severe symptoms and their controlled transition to polymeric enteral formulas.

The Natural Anthraquinone Parietin Inactivates Candida tropicalis Biofilm by Photodynamic Mechanisms

Background/Objectives: Parietin (PTN), a blue-light absorbing pigment from Teloschistes spp. lichens, exhibit photosensitizing properties via Type I (superoxide anion, O2•-) and Type II (singlet oxygen, 1O2) mechanisms, inactivating bacteria in vitro after photoexcitation. We evaluate the in vitro antifungal activity of PTN against Candida tropicalis biofilms under actinic irradiation, its role in O2•- and 1O2 production, and the cellular stress response. Methods: Minimum inhibitory concentration (MIC) of PTN was determined in C. tropicalis NCPF 3111 under dark and actinic light conditions. Biofilm susceptibility was assessed at MIC/2, MIC, MICx2, MICx4, and MICx6 in the same conditions, and viability was measured by colony-forming units. Photodynamic mechanisms were examined using Tiron (O2•- scavenger) or sodium azide (1O2 quencher). O2•- production was measured by the nitro-blue tetrazolium (NBT) reduction and nitric oxide (NO) generation by Griess assay. Total antioxidant capacity was studied by FRAP (Ferrous Reduction Antioxidant Potency) assay and superoxide dismutase (SOD) activity by NBT assay. Results: Photoexcitation of PTN reduced C. tropicalis biofilm viability by four logs at MICx2. Sodium azide partially reversed the effect, whereas Tiron fully inhibited it, indicating the critical role of O2•-. PTN also increased O2•- and NO levels, enhancing SOD activity and FRAP. However, this antioxidant response was insufficient to prevent biofilm photoinactivation. Conclusions: Photoinactivation of C. tropicalis biofilms by PTN is primarily mediated by O2•-, with a minor contribution from 1O2 and an imbalance in NO levels. These findings suggest PTN is a promising photosensitizer for antifungal photodynamic therapy.

Outcomes and cost-effectiveness of intermediate care units for patients discharged from the intensive care unit: a nationwide retrospective observational study

BACKGROUND

The clinical and economic impacts of intermediate care units (IMCUs) on intensive care unit (ICU)-discharged patients remain unclear due to inconsistent outcomes in previous studies. Under Japan's National Health Insurance Scheme, ICUs are categorized by staffing intensity (high or low). Using a nationwide inpatient database in Japan, we evaluated the clinical outcomes and cost-effectiveness of IMCUs for ICU-discharged patients.

METHODS

This retrospective observational study used a Japanese administrative database to identify patients admitted to the high-intensity ICU in hospitals with IMCUs between April 2020 and March 2023. Patients were categorized into the IMCU (IMCU group) and general ward (non-IMCU) groups. Propensity scores were estimated using a logistic regression model incorporating 14 variables, including patient demographics, and treatments received during ICU stay. One-to-one propensity score matching balanced baseline characteristics of each group. Clinical outcomes were compared between both groups, including in-hospital mortality, ICU readmission, length of ICU stay, length of hospital stay, and total medical costs. Surgical status and surgical area (e.g., cardiovascular) were considered in subgroup analyses. Data analyses were conducted using the chi-square test for categorical variables and t-test for continuous variables.

RESULTS

Overall, 162,243 eligible patients were categorized into the IMCU (n = 21,548) and non-IMCU (n = 140,695) groups. Propensity score matching generated 18,220 pairs. The IMCU group had lower in-hospital mortality and ICU readmission rates than the non-IMCU group. However, total costs were higher in the IMCU group. Subgroup analyses revealed the IMCU group had significantly lower mortality and lower total costs than the non-IMCU group in the cardiovascular [open thoracotomy] surgery subgroup.

CONCLUSIONS

Discharge to an IMCU is associated with lower in-hospital mortality and ICU readmission rates compared to general ward discharge. High-risk subgroups, such as cardiovascular surgery patients, experienced cost-effective benefits from IMCU care. These findings highlight an association between IMCU admission and improved patient outcomes, suggesting a potential role in optimizing resource use in intensive care. Given the likelihood of selection bias in admission allocation, these findings should be interpretation with caution.

Myokine Secretion Dynamics and Their Role in Critically Ill Patients: A Scoping Review

Background/Objectives: Myokines can modulate organ function and metabolism, offering a protective profile against ICU complications beyond preventing local muscle wasting. This scoping review aims to explore and summarize the evidence regarding the secretion of myokines and their potential local or systemic effects in critically ill patients. Methods: A scoping review following Joana Briggs Institute recommendations was conducted. A systematic search of MEDLINE (Ovid), Embase (Ovid), CENTRAL, CINAHL (EBSCOhost), WoS, and Scopus was conducted from inception to February 2023. We included primary studies evaluating myokine secretion/concentration in critically ill adults undergoing physical rehabilitation interventions. Two independent reviewers performed study selection and data extraction. Results: Seventeen studies published between 2012 and 2023 were included. Most were randomized clinical trials (47%). Physical rehabilitation interventions included electrical muscle stimulation, as well as passive and active mobilization, delivered alone or combined, in single or daily sessions lasting 20-60 min. Twelve studies (70%) evaluated interleukin-6, while interleukin-10, tumour necrosis factor-α, Interleukin-8, and myostatin were also commonly studied. Thirteen studies (76%) reported changes in myokine secretion or gene expression, although no clear concentration change pattern emerged. Myokines involved in muscle protein synthesis and breakdown may protect against muscle waste and weakness. Conclusions: The study of myokine dynamics in critically ill patients highlights the systemic impact of physical rehabilitation. This emerging field has grown in interest over the past decade, offering significant research potential. However, challenges such as study design, small sample sizes, and variability in physical therapy protocols hinder a comprehensive understanding of myokine responses.

Case Report: Fatal case of dual infection Metapneumovirus complicated by Streptococcus pyogenes

Human Metapneumovirus (hMPV) is a common cause of acute respiratory viral infection in humans, typically occurring in children and causing no serious complications. However, the severity of the disease can be exacerbated by certain bacterial pathogens that lead to severe illness and even death. This report details a fulminant case of dual infection with hMPV and group A Streptococcus (Streptococcus pyogenes) in a three-year-old child. The whole genome sequencing of isolated clinical S. pyogenes strains was conducted, followed by an analysis of the genomic characteristics of the pathogen. Also, potential viral and bacterial pathogens were identified by qPCR and 16S rRNA metagenomic sequencing in any autopsy materials obtained from the patient. Children who had contact with the patient and began to exhibit symptoms of a cold were also tested and confirmed to have uncomplicated hMPV infection. The S. pyogenes strain has been found to contain five genes for various streptococcal exotoxins (speA, speB, speJ, speG and smeZ). In addition, the speA gene is situated in close proximity to the prophage, which may suggest that it is encoded and transferred specifically by the bacteriophage. We hypothesize that it was the cumulative effects of different streptococcal exotoxins that led to the patient's death.

Hemodynamic Monitoring During Liver Transplantation for Patients on Perioperative Extracorporeal Membrane Oxygenation (ECMO) Support: A Narrative Review

Background and Objectives: Indications for liver transplants are increasing worldwide due to the growing number of transplants performed on patients with significant cardiovascular and respiratory risk factors. Additional support for this trend comes from the growing use of marginal organs, which is made possible by donations made after circulatory death (DCD). Liver transplantation (LT) in such high-risk patients may be challenging and may require perioperative Extracorporeal Membrane Oxygenation (ECMO). There is a lack of evidence on the best hemodynamic monitoring techniques for patients undergoing ECMO support during the perioperative period of LT. This review aims to provide a comprehensive overview of the hemodynamic monitoring standards of patients supported by ECMO before, during, and after LT. Materials and Methods: Comprehensive research was conducted through the PubMed database, and 153 articles regarding patients who needed perioperative ECMO support were found. Among these, 18 articles were finally included in our analysis as the authors specified hemodynamic monitoring techniques and data. The articles included case reports, letters to the editor, and correspondence. Results: We identified 20 cases of patients supported by ECMO as a planned preoperative strategy (9 patients), as a rescue therapy during surgery (7 patients), and as a postoperative support (4 patients). Cardiac catheterism and echocardiography (transthoracic and transesophageal) were the authors' most cited hemodynamic monitoring techniques. Conclusions: Data on hemodynamic monitoring methods used to manage patients supported by ECMO during the whole perioperative period of LT are poor and derived from descriptive low-quality studies. However, a multimodal approach that includes continuous monitoring of pulmonary pressures and echocardiography can increase diagnostic accuracy and improve the decision-making process to manage this complex patient population.

Pathogen Profile of Children Hospitalised with Viral Respiratory Infections in Galati County, Romania

Respiratory infections are the most common infectious diseases among children, representing a cause of death and generating a significant number of hospitalisations. The aim of the study was to analyse the epidemiological and clinical characteristics of viral pathogens causing respiratory tract infections in newborns and young children admitted to Galati pediatric hospital between October 2022 and December 2023. The diagnosis was performed using multiplex RT-PCR panels, which allowed simultaneous identification of respiratory pathogens (viruses and bacteria). From a total of 803 hospitalised patients with respiratory diseases, 607 (75.6%) children had a positive result for at least one respiratory virus and 96 patients (11.9%) were identified with bacterial infections. Mixed coinfections were found in almost half of the patients (44.5%). Most of RSV positive children had an increased length of stay, more than 7 days. It was shown a decline in severe cases of viral respiratory infections with prolonged hospitalisation as patients age up to 5 years.

Increased risk during winter: common respiratory viruses and clinical outcomes in hospitalized children

BACKGROUND

Acute respiratory infections (ARIs) are a leading cause of hospitalisation, severe morbidity, and mortality in children, representing a significant public health concern. This study aimed to evaluate the clinical features, laboratory findings, and outcomes of pediatric patients hospitalised due to ARIs caused by common respiratory viruses, including influenza virüs (IFV), human bocavirus (hBoV), human metapneumovirus(hMPV), human rhinovirus (hRV), and human respiratory syncytial virüs (hRSV).

METHODS

We conducted a retrospective analysis of 1465 hospitalized pediatric patients at Ankara Bilkent City Hospital Children's Hospital between August 2019 and March 2024. Nasopharyngeal swabs were analyzed using multiplex real-time PCR to identify viral pathogens. Clinical data, including demographics, intensive care needs, respiratory support, and chronic health conditions, were reviewed.

RESULTS

A total of 1465 hospitalized children were included in the study, with a median age of 3 years and 61.8% being male. Of these patients, 32.9% (n = 482) had chronic health conditions. IFV was detected in 30.1% of patients, hBoV in 28.3%, hRSV in 18.4%, hRV in 14.4%, and hMPV in 8.8%. Over half of the infections occurred during the winter months, with IFV being the most commonly observed virus. Fever was most frequently observed in IFV cases, while cough and hypoxia were more prevalent in hBoV and hRSV infections. Admission to the Pediatric Intensive Care Unit was necessary in 19.5% of cases, with 33.1% of these requiring invasive mechanical ventilation. Invasive mechanical ventilation was most frequently required in hBoV cases. The mortality rate was 8.7%, predominantly observed in patients with chronic health conditions; hBoV was associated with the highest mortality.

CONCLUSION

This study provides a comprehensive analysis of the clinical, laboratory, and radiological characteristics of children hospitalized due to viral lower respiratory tract infections, offering valuable insights into common respiratory pathogens. The findings underscore a higher incidence of these infections during the winter months. It is recommended that hBoV and IFV infections be closely monitored in children with underlying chronic conditions. Moreover, the study highlights the importance of meticulous management of hBoV and hRSV infections, given their association with an increased need for intensive care support.

Rhabdomyosarcoma in adults with severe thrombocytopenia: Challenges in clinical management and therapeutic complications

Alveolar rhabdomyosarcoma (ARMS) in adults is a rare condition with a poor prognosis compared to other subtypes. The management of this pathology is complex due to the lack of standardized guidelines and the limited response to multimodal treatments, including chemotherapy, radiotherapy, and surgery. We report the case of a 40-year-old male with stage IV ARMS and pulmonary metastasis, who underwent resection of right supraclavicular sarcoma and cervical lymph node dissection. He was later referred for palliative chemotherapy following an acute clinical presentation lasting two days, characterized by right facial edema, inflammation, ulceration, and severe pain. Initial treatment included ampicillin/sulbactam, trimethoprim/sulfamethoxazole, and dexamethasone. Chemotherapy with doxorubicin and ifosfamide was delayed due to thrombocytopenia, elevated D-dimer and fibrinogen levels, and an echocardiographic finding that required differentiation between thrombus and metastatic lesion. Anticoagulation with fondaparinux and transfusions were initiated, and the patient received 10 sessions of radiotherapy. During hospitalization, the patient developed orthopnea, pleural effusion, superior vena cava syndrome, and hemodynamic deterioration, necessitating vasopressor support and mechanical ventilation. Despite these interventions, the patient progressed to refractory shock, severe hypoxemia, and died from cardiac arrest. This case highlights the challenges in managing ARMS in adults with severe thrombocytopenia.

Current Management and Future Challenges in the Management of Severe Traumatic Brain Injury

Background and Objectives: Severe Traumatic Brain Injury (TBI) is one of the devastating injuries occurring in all ages across the globe. Despite many advancements in the management of severe TBI, mortality and morbidities remain high. Evidence-based management in severe TBI has reduced mortality. The purpose of this review is to discuss the current management and present the future challenges in this patient cohort. Materials and Methods: A literature review was conducted to identify the current practice patterns and guidelines of severe TBI. We examined the literature regarding medical and surgical managements of the severe TBI. Results: Initial management of severe TBI includes stabilization of the primary injury and prevention of secondary insult to brain. Hemodynamic, intracranial pressure and cerebral perfusion pressure monitoring, antiseizure prophylaxis, hyperosmolar therapy, sedation, medical induced coma, and nutritional and ventilatory support are part of the medical management. Operative intervention includes craniotomy and decompressive craniectomy. Most of the current practices are recommended by the Brain Trauma Foundation (BTF). These guidelines are based on the existing literature, however, some of the recommendations by the BTF lack level one evidence. Conclusions: BTF guidelines provide recommendations in the management of severe TBI. High quality prospective randomized trials are needed to further explore the new modalities and interventions in the field of severe TBI.

Association Between Nursing Workload and Intensive Care Unit Readmissions: A Prospective Cohort Study

AIM

The aim of this study was to assess the relationship between nursing workload at the time of intensive care unit discharge and the likelihood of intensive care unit readmission.

DESIGN

This single-center prospective cohort study was conducted at a Belgian academic hospital and included all intensive care unit admissions from June 1, 2021 to May 31, 2022.

METHODS

The Nursing Activities Score was documented by the nurse responsible for each patient during every shift. Adult patients (≥ 18 years) with intensive care unit stay exceeding 24 h during the study period were eligible for inclusion. Those discharged to another hospital, a nursing home, or their own home were excluded due to the inability to ensure follow-up.

RESULTS

Among the 1293 eligible admissions recorded during the study period, 133 patients (10.3%) experienced readmission. Readmitted patients exhibited a higher prevalence of medical reasons for intensive care unit admission, significantly increased mortality rates, and longer hospital length of stay compared to non-readmitted patients. The average daily Nursing Activities Score did not differ significantly between the two groups. The Nursing Activities Score at intensive care unit discharge was notably higher in readmitted patients, and those with a score above the median at discharge demonstrated an increased risk of readmission within 30 days. In multivariable analysis, a high Nursing Activities Score at intensive care unit discharge was an independent predictor of readmission.

CONCLUSIONS

An elevated nursing workload, as indicated by the Nursing Activities Score recorded at intensive care unit discharge, was significantly associated with a higher risk of readmission.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

The study examines the relationship between nursing workload at the time of ICU discharge and the likelihood of unplanned readmission. The results highlight the critical role of nursing workload assessment at ICU discharge in capturing the complexity of care requirements patients face at discharge. The results emphasise the importance of revising discharge planning processes, identifying nursing workload as a critical factor in unplanned readmissions.

REPORTING METHOD

STROBE guidelines were used for this study.

PATIENT OR PUBLIC CONTRIBUTION

Not applicable.

Integrating Lean Six Sigma into Microbiology Laboratories: Insights from a Literature Review

BACKGROUND/OBJECTIVES

Clinical laboratories are fundamental to healthcare systems, contributing to over 70% of clinical decisions while accounting for only 2-3% of hospital budgets. Among them, microbiology laboratories provide critical information that directly influences patient outcomes and satisfaction. This study presents a structured review of the current state of Lean Six Sigma (LSS) implementation in microbiology and comparable laboratory environments. The objective is to identify relevant contributions within the state of the art to highlight potential benefits applicable to microbiology laboratories and to detect persistent gaps and unresolved needs.

METHODS

A systematic literature review was performed across six databases (Web of Science, ScienceDirect, Scopus, ProQuest, PubMed, and Google Scholar) to identify studies published between 2012 and September 2024. After screening, 33 studies were selected for full-text analysis.

RESULTS

The selected literature was analyzed to assess the extent to which LSS methodologies have been applied in microbiology laboratories. Particular attention was given to the definition and use of key performance indicators (KPIs). While industry-adapted metrics such as cost reduction and turnaround time are commonly employed, clinical indicators, such as patient impact, satisfaction, and diagnostic accuracy, are underutilized. Additionally, the analysis revealed a frequent omission of the control phase in LSS projects, limiting long-term process monitoring. The review also identifies the most suitable LSS tools and evaluates how laboratories manage interruptions in routine workflows.

CONCLUSIONS

Future research should prioritize the integration of clinical KPIs into LSS frameworks, establish robust control phases for sustained monitoring, and systematically address the impact of process interruptions on optimization efforts.

Comparison of video laryngoscopy with direct laryngoscopy in critically ill patients: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Although Video laryngoscope (VL) can reduce the difficulty of endotracheal intubation and improve the glottic view, its use in critically ill patients is controversial.

METHODS

Randomized controlled trials (RCTs) of VL and direct laryngoscopy (DL) for critically ill patients were searched on electronic databases, including Web of Science, PubMed, and Embase. Additional publications were identified by screening the reference lists of the identified articles and relevant previously published reviews.

RESULTS

Overall, 25 RCTs involving 5836 critically ill patients were included in the analysis. There was no significant difference in the first intubation rate between the VL and DL groups (25 studies; RR, 1.03; 95% CI 0.96-1.11; n = 5836; p = 0.37; very low certainty). However, Multivariate meta-regression analysis identified two main sources of bias: whether intubation was performed in a hospital (p = 0.04) and operator proficiency with DL compared to VL (p < 0.001). Subgroup analysis showed that VL improved the first intubation rate in in-hospital intubation (19 studies; RR, 1.12; 95% CI 1.04-1.22; n = 4441; p < 0.01, very low certainty) and VL showed good potential to reduce the first-attempt intubation success rates, but not significantly (6 studies; RR, 0.75; 95% CI 0.56-1.00; n = 1395; p = 0.05, very low certainty). In subgroups with similar operator proficiency VL and DL, VL increased the success rate for first intubation (16 studies; RR, 1.14; 95% CI 1.06-1.23; n = 3,971; p < 0.01; very low certainty). However, VL decreased the first intubation rate (4 studies; RR, 0.65; 95% CI 0.49-0.88; n = 810; p < 0.01; very low certainty) in a subgroup where operator proficiency was higher for DL than for VL.

CONCLUSION

VL does not increase the first intubation rate. However, VL increases the first-attempt intubation success rate for in-hospital intubation and operators with similar proficiency in VL and DL.

Vitamin D and Acute Kidney Injury: A Reciprocal Relationship

Vitamin D is a sterol prohormone with no intrinsic biological activity. Calcitriol, the active form of vitamin D, is synthesized in the kidneys. It has well-known pleiotropic and cytoprotective properties. In addition to regulating parathyroid hormone secretion and enhancing gut calcium absorption, it exhibits antioxidant, anti-inflammatory, antiproliferative, and antineoplastic effects. However, the role of vitamin D in AKI is unclear, unlike in CKD. Thus, this review aimed to understand how dysregulated vitamin D homeostasis occurs in AKI, as well as to explore how vitamin D deficiency and excess influence AKI. A comprehensive literature search was conducted between January 2000 and June 2024 to uncover relevant works detailing vitamin D homeostasis in health as well as investigating the impact of vitamin D deficiency and excess in humans, animals, and in vitro cell models of AKI. According to the findings of this review, vitamin D appears to have a reciprocal relationship with AKI. Acute renal injury, among other factors, can cause hypo- or hypervitaminosis D. Conversely, AKI can also be caused by vitamin D deficiency and toxicity. Even though hypovitaminosis D is associated with AKI, it is uncertain how it impacts AKI outcomes in distinct clinical scenarios. Newer therapeutic options might emerge as a result of understanding these challenges. Vitamin D supplementation may ameliorate renal injury but needs further validation. Furthermore, hypervitaminosis D has also been implicated in AKI by causing hypercalcemia and hyperphosphatemia. It is crucial to avoid prolonged, uncontrolled, and unsupervised supraphysiological vitamin D administration, especially intramuscular injection.

Protein C in adult patients with sepsis: from pathophysiology to monitoring and supplementation

Protein C (PC) plays a crucial role in modulating inflammation and coagulation in sepsis. Its anticoagulant and cytoprotective properties are critical in mitigating sepsis-induced coagulopathy, which is associated with high mortality rates. In sepsis, low levels of PC are associated with an elevated risk of multiple organ dysfunction and increased mortality. Routine monitoring of PC levels is not widely implemented but appears relevant in selected populations, such as patients with purpura fulminans, sepsis-induced coagulopathy (SIC), disseminated intravascular coagulopathy (DIC) or hyperinflammatory septic shock phenotypes. Treatment with PC has been limited to PC concentrate approved for paediatric use in congenital PC deficiencies and purpura fulminans, while the efficacy of PC supplementation in sepsis remains a subject of debate. Considering the physiological significance of PC and its role in sepsis pathophysiology, additional studies are necessary to fully elucidate its therapeutic efficacy in specific clinical settings.

The SaRePo protocol: A seven-step strategy to minimize complications potentially related to the removal of totally implanted central venous access devices

Removal of totally implanted central venous access devices (brachial ports, chest-ports, femoral ports) is potentially associated with the risk of untoward events, some of them negligible (prolonged maneuver time due to technical difficulties), some relevant (hematoma), and some severe (embolization of catheter fragments into the circulation). The removal technique suitable for minimizing such complications has been described only in few manuals, but it has never been standardized. This paper describes a standardized protocol (SaRePo: Safe Removal of Ports) which consists of seven basic strategies to be adopted systematically during removal of totally implanted venous access devices, so to minimize the risk of adverse events. These strategies include: evaluation of the patient's history, preprocedural ultrasound scan of the veins, appropriate aseptic technique, proper local anesthesia, catheter extraction, removal of the reservoir from the pocket, closure of the surgical incision.

Planning intensive care unit admission after elective major abdominal surgery: good clinical practice document by SIAARTI-SIC-ANIARTI

Postoperative complications (PCs) are a major cause of mortality following elective major abdominal surgery (EMAS). The increasing complexity of abdominal procedures, particularly in oncology, may significantly affect patient outcomes. However, this has also introduced a higher variability in postoperative management, and the use of tailored approaches to address critical issues such as hemodynamic stabilization, infection management, and respiratory failure. While elective admission to intensive care units (ICU) is a standard practice to manage high-risk surgical patients, ICU resource allocation is often influenced by local practices and bed availability.This document presents a framework for preoperative ICU admission planning after EMAS. It focuses on the identification of patient and surgical risk factors-using established scoring systems-and provides statements to determine ICU admission. The aim is to optimize resource allocation, reduce PCs, and prevent unplanned ICU admissions. This good clinical practice statement was developed through a multidisciplinary panel formed by selected members coming from SIAARTI (Italian Society of Anesthesia Analgesia Resuscitation and Intensive Care), SIC (Italian Society of Surgery) and ANIARTI (National Association of Critical Area Nurses).The designed scientific board developed, through a systematic literature review and a consensus methodology, a roadmap for defining the priorities of perioperative care based on the complexity of the patient and the surgical procedure. Eventually, the panel worked out statements about six voted queries that could have supported the preoperative indication to postoperative ICU admission.Evaluation of patients' characteristics, comorbidities, and surgical factors are all essential to plan ICU admission for immediate postoperative patient care after EMAS.The presence and severity of comorbidities, assessed through various severity scores, play a crucial role in predicting PCs and guiding ICU admission decisions. Tools such as the American Society of Anesthesiologists physical status, Charlson Comorbidity Index, and Rockwood Frailty Index, along with surgical risk scores and intraoperative events, help define the need for intensive care. Preoperative frailty assessment-achieved using the Clinical Frailty Scale-is essential to anticipate postoperative care needs. Finally, during the postoperative phase, continuous monitoring and reassessment in the post-anesthesia care unit are key to determine whether ICU admission is required. Establishing high-dependency units and tailored care pathways based on individual patient needs and available resources will enhance patient outcomes and optimize postoperative care.

Model for estimating the risk of postoperative morbidity and optimizing patients' management after hepatectomy

BACKGROUND

Early detection of major complications and immediate therapeutic interventions may improve patient outcome after hepatectomy. The aim of the present study was to develop a model predicting the risk of postoperative complications after hepatectomy and help identify patients who require close-monitoring in intensive care unit (ICU).

METHODS

Patients underwent hepatectomy at Humanitas Research Hospital, Italy, between 2010 and 2021 were considered. We used preoperative, intraoperative and combined predictors to build three models predicting Clavien-Dindo III-V complications. Model performances was evaluated internally via bootstrapping.

RESULTS

Of 1497 patients, 7% had Clavien-Dindo III-V complications. Tumor pathology, tumor burden, previous chemotherapy, liver characteristics, clinical portal hypertension, cardiopathy, creatinine and total protein level were incorporated in the preoperative model. In addition to these variables, type of hepatectomy, operation time, additional surgical procedure, and transfusion were incorporated into the combined model. The bootstrap corrected C-indices for preoperative, intraoperative and combined models were 0.68, 0.70 and 0.72. The median predicted probability of major complications over-1000 bootstraps was close to observed probabilities for all models.

CONCLUSION

These prognostic models may help identify patients at high-risk of major complication and guide decision-making for individual patients and postoperative ICU-care assessment. Observed optimism in model performance necessitates external validation.

A new community-based cardiopulmonary resuscitation training program for primary care: needs assessment, development, and pilot testing

OBJECTIVE

The general population's interest in cardiopulmonary resuscitation (CPR) remains largely unknown. Fewer than one-third of individuals are familiar with CPR, and there are no comprehensive training programs available. This study aimed to examine CPR interest among patients visited in the primary care setting, design a new program, and assess the feasibility and efficacy of the training initiative.

METHODS

This two-phase project aimed to (i) examine patients' knowledge and interests and (ii) design and evaluate a training program within the PC setting. Knowledge and interests were assessed using a survey. The training program design adhered to European guidelines. The pilot study assessed effectiveness through self-administered tests, instructor evaluation of the chain of survival, correct use of an automated external defibrillator (AED), and a manikin capable of measuring chest compression.

RESULTS

A total of 243 patients participated. Among them, 26.16% had received prior CPR training, only 5% knew how to perform CPR maneuvers, and 84.8% were interested in learning. A 90-min training program was designed. After the training session (N = 50), all participants reported feeling capable of performing CPR techniques using the AED; 94% demonstrated proficiency in AED use, and 20% performed high-quality chest compressions (correct release, depth, and rate).

CONCLUSION

The general population had limited knowledge about CPR but was highly interested in acquiring CPR skills. The PC-based training program enabled bystanders to perform CPR and use AEDs, potentially improving survival rates in out-of-hospital cardiac arrests.

Lactate and CO2-derived parameters are not predictive factors of major postoperative complications after cardiac surgery with cardiopulmonary bypass: a diagnostic accuracy study

Purpose

This study aimed to compare the performance of lactate and CO2-derived parameters in predicting major postoperative complications (MPC) after cardiac surgery with cardiopulmonary bypass.

Methods

Lactate and CO2-derived parameters, including the venous-arterial difference in CO2 partial pressure (Pv-aCO2), the venous-arterial difference in CO2 partial pressure to arterial-venous O2 content ratio (Pv-aCO2/Ca-vO2), and the venous-arterial difference in CO2 content to arterial-venous O2 content ratio (Cv-aCO2/Ca-vO2) at ICU admission, 3 h, 6 h, and 12 h later were collected. Receiver-operating characteristics (ROC) curve analysis was carried out to assess the predictive performance. Univariate and multivariate logistic regression analyses were performed to identify independent predictors of MPC.

Results

MPC occurred in 77 (54.2%) of 142 patients. No significant difference was observed between the MPC and no-MPC groups regarding lactate and CO2-derived parameters. The area under the curves (AUCs) were 0.532 (0.446-0.616) for lactate, 0.559 (0.473-0.642) for Pv-aCO2, 0.617 (0.532-0.697) for Pv-aCO2/Ca-vO2, and 0.625 (0.540-0.705) for Cv-aCO2/Ca-vO2, respectively, and there was no significant difference between the parameters. In the post-hoc analysis, all parameters' AUCs were lower than 0.75 in predicting acute renal failure, and there was no significant difference between these parameters. Cv-aCO2/Ca-vO2 at 12 h yielded the highest AUC of 0.853 (0.784-0.907) in predicting mortality and the highest AUC of 0.808 (0.733-0.869) in predicting delirium. In multivariate analysis, hypertension, surgery duration, and PaO2/FiO2 were identified as independent predictors of MPC, while lactate and CO2-derived parameters lost statistical significance after adjustment for covariates.

Conclusions

Lactate and CO2-derived parameters cannot be used as reliable indicators to predict the occurrence of MPC after cardiopulmonary bypass. Instead, traditional clinical factors such as hypertension, extended surgical duration, and impaired oxygenation emerged as the most reliable risk indicators.

Comprehensive analyses: Using machine learning models for mortality prediction in the intensive care unit of internal medicine

Mortality prediction in the intensive care unit (ICU) is essential in patient management. Emerging methods such as machine learning (ML) can be employed to predict ICU patients' mortality. Patients receiving treatment in the ICU of the internal medicine department were subjected to ML analysis upon admission, considering demographic, laboratory, and medical scores. Data from 787 internal medicine ICU patients were analyzed, with only a subset (220) included in the study for the 30-day mortality prediction model. The performance of boosting and Logistic Regression models in mortality prediction was compared. Categorical boosting (CatBoost) achieved the highest area under the curve (AUC) of 0.90, while extreme gradient boosting reached a maximum AUC of 0.85, and Logistic Regression attained the highest AUC of 0.83. Incorporating Acute Physiology and Chronic Health Evaluation II, Simplified Acute Physiology Score II, and Sequential Organ Failure Assessment scores with clinical and laboratory values, CatBoost demonstrated the strongest predictive performance with high sensitivity and specificity. In the ICU of the internal medicine department, it was concluded that the ML models successfully predict mortality.

Reliability of differential time to positivity technique for diagnosing catheter-related bloodstream infections: a retrospective analysis

The differential time to positivity (DTTP) technique is the recommended conservative procedure to diagnose catheter-related bloodstream infection (C-RBSI). However, its reliability and accuracy remain under debate. Therefore, we aimed to compare the DTTP technique feasibility to detect C-RBSI compared to the catheter culture (CC) method. We conducted a 9-month retrospective study including bacteremic episodes in which both DTTP blood cultures (BC) and CC were obtained. We analyzed the diagnostic validity of the DTTP technique for detecting C-RBSI compared to the gold standard (C-RBSI with CC), along with patient clinical data. We included 37 episodes of C-RBSI where both DTTP BC and CC were obtained. C-RBSI was confirmed by both techniques in only 13 episodes (35.1%), whereas in 11 (29.7%) and 13 (35.1%), only DTTP BC or DTTP BC with CC (with a difference between catheter lumen and peripheral BC growth of <2 hours) was positive, respectively. Therefore, the validity values of the DTTP technique for predicting C-RBSI were as follows: sensitivity, 50.0%; specificity, 71.8%; positive predictive value, 54.2%; and negative predictive value, 68.3%. The distribution of microorganisms was similar among the three groups. All patients in whom colonization was not demonstrated by CC (n = 11) had been receiving antibiotics before catheter withdrawal. DTTP is a conservative technique that might help to diagnose C-RBSI mostly in situations where catheter removal cannot be achieved. However, it should be interpreted with caution and never be used to rule out C-RBSI. CC before starting antimicrobial therapy remains the most reliable method to diagnose and confirm an episode of C-RBSI.IMPORTANCEWe try to clarify the reliability of the differential time to positivity technique to predict C-RBSI. It may be interpreted with caution and considering clinical signs, as some C-RBSI can be misdiagnosed.

Deciphering the impact of sepsis phenotypes on improving clinical outcome predictions: a multicenter retrospective analysis based on critical care in China

Sepsis is a clinically heterogeneous disease with high mortality. It is crucial to develop relevant therapeutic strategies for different sepsis phenotypes, but the impact of phenotypes on patients' clinical outcomes is unclear. This study aimed to identify potential sepsis phenotypes using readily available clinical parameters and assess their predictive value for 28-day clinical outcomes by logistic regression analysis. In this retrospective analysis, researchers extracted clinical data from adult patients admitted to the First Affiliated Hospital of Anhui Medical University between April and August 2022 and from the 2014-2015 eICU Collaborative Study database. K-Means clustering was utilized to identify and refine sepsis phenotypes, and their predictive performance was subsequently evaluated. Logistic regression models were trained independently for each phenotype and five-fold cross-validation was used to predict clinical outcomes. Predictive accuracy was then compared to traditional non-clustered prediction methods using model assessment scores. The study cohort consisted of 250 patients from the First Affiliated Hospital of Anhui Medical University, allocated in a 7:3 ratio for training and testing, respectively, and an external validation cohort of 3100 patients from the eICU Cooperative Research Database. The results of the phenotype-based prediction model demonstrated an improvement in F1 score from 0.74 to 0.82 and AUC from 0.74(95%CI 0.71-0.80) to 0.84(95%CI 0.82-0.87), and these results also highlight the superiority of clinical outcome prediction with the help of sepsis phenotypes over traditional prediction methods. Phenotype-based prediction of 28-day clinical outcomes in sepsis demonstrated significant advantages over traditional models, highlighting the impact of phenotype-driven modeling on clinical outcomes in sepsis.

Accuracy of point-of-care ultrasound examination of the lung in primary care performed by general practitioners: a cross-sectional study

BACKGROUND

Lung ultrasonography (LUS) is a point-of-care imaging modality with growing potential in primary care.

OBJECTIVES

While its use is well established in hospital settings, data on its accuracy when performed by general practitioners (GPs) remain limited. This study aimed to assess the diagnostic accuracy of LUS conducted by GPs following structured training.

METHODS

We recruited 17 GPs from various regions of the Czech Republic. They completed a two-day educational course focused on LUS. Patients with current dyspnoea (NYHA II-IV) or a history of dyspnoea within the last four weeks were included and underwent LUS to assess the presence of pleural effusion and interstitial syndrome. An independent expert sonographer, blinded to clinical data, evaluated recorded LUS video loops as the reference standard. LUS findings were categorized into A profile (presence of A lines and intact lung sliding, indicating normal aeration), B profile (three or more B lines per intercostal space in at least two intercostal spaces per hemithorax, suggesting interstitial syndrome), pulmonary consolidation and pleural effusion.

RESULTS

A total of 128 patients were enrolled in the study. A total of 768 thoracic segments were examined. A profile was identified in 642 (83.6%) segments, B profile in 108 (14.1%), pulmonary consolidation in 8 (1.0%), and pleural effusion in 12 (1.6%). For the identification of A profile, the sensitivity was 97.51% (95% CI 95.98-98.57), and the specificity was 88.10% (95% CI 81,13-93,18); for B profile, the sensitivity was 87.04% (95% CI 79,21-92,73), and the specificity was 97.73% (95% CI96,28-98,72); for pulmonary consolidation, the sensitivity was 100.0% (95% CI 63,06-100,00), and the specificity was 100.0% (95% CI 99,52-100,0); for pleural effusion, the sensitivity was 83.33% (95% CI 51,59-97,91), and the specificity was 99.87% (95% CI 99,27-100,00).

CONCLUSION

Our findings provide important preliminary data, demonstrating that GPs can perform LUS accurately after a structured training program. THE TRIAL REGISTRATION IDENTIFIER: is NCT04905719.

Major Histocompatibility Complex Class I and II Allele Frequencies and Disease Associations in Mexicans: A Systematic Review and Meta-Analysis

BACKGROUND

The major histocompatibility complex (MHC) plays a crucial role in immune responses and is associated with disease susceptibility. This study systematically reviews MHC class I and class II allele frequencies and their associations with diseases in the Mexican population from 1979 to 2023.

METHODS

A systematic review following PRISMA guidelines was conducted. Reports were obtained from the Allele Frequency Net Database and PubMed using keywords related to HLA and Mexican populations. A total of 776 reports were screened, and 214 were retained for final analysis. Seventy-six studies comprising allele frequency data from over 20,000 individuals across Mexican states and indigenous communities were analyzed. In addition, over 138 articles were examined to identify alleles associated with various diseases.

RESULTS

The analysis identified 117 alleles whose frequencies varied regionally within Mexico. While DPA1*01, DPB1*04:01, and DQA1*03 were predominant, DRB1*04, DQB1*03, and DQA1*05 were also prominent but variable. Certain alleles, such as A*02, B*35, C*04, and C*07, were relatively common in the population. Numerous disease correlations were uncovered, such as B*27's strong association with spondyloarthropathies. DRB1*15:01 and DRB1*04 conferred an increase in multiple sclerosis, while DRB1*04 may protect against some skin diseases.

CONCLUSION

This review improves the understanding of MHC allele frequencies and disease associations in Mexicans, highlighting genetic diversity. The findings lay the groundwork for future research on genetic predispositions and health outcomes, aiding healthcare strategies in this diverse population. Further studies are needed to address data gaps and refine genetic profiles for targeted medical applications.

Stepwise improvement in intracerebral haematoma expansion prediction with advanced imaging: a comprehensive comparison of existing scores

BACKGROUND

We aim to comprehensively assess and compare the predictive performance of haematoma expansion (HE) scores in a homogeneous cohort of acute intracerebral haemorrhage (ICH) patients.

METHODS

Existing scores for predicting HE in acute ICH patients were included and categorised by imaging modality: non-contrast CT (NCCT), single-phase CT angiography (sCTA) and multiphase CTA (mCTA). The predictive performance of the scores was evaluated with the c-statistic in a population of consecutive adult patients with acute ICH admitted to a tertiary care centre in Southern Alberta, Canada, between February 2012 and May 2020, investigated with a multimodal imaging protocol (NCCT, sCTA and mCTA). The primary outcome was HE (ICH volume growth ≥6 mL or ≥33%), and the secondary outcome was severe HE (ICH volume growth ≥12.5 mL or ≥66%). The DeLong test compared the best-performing scores from each imaging category.

RESULTS

16 HE scores were assessed (NCCT=8, sCTA=6 and mCTA=2) in 217 patients with a median age of 70 years (IQR=60-80), and 86 (39.6%) were females. 51 (23.5%) patients experienced HE and 35 (16.1%) had severe HE. The c-statistic for predicting HE ranged from 0.516 to 0.674 for NCCT-based scores, 0.627 to 0.725 for sCTA-based scores and 0.800 to 0.814 for mCTA-based score. The c-statistic for predicting severe HE ranged from 0.505 to 0.666 for NCCT scores, 0.651 to 0.740 for sCTA scores and 0.813 to 0.828 for mCTA scores. A statistically significant difference favouring mCTA over other imaging modalities in predicting both HE and severe HE was observed.

CONCLUSIONS

Advanced imaging demonstrated a stepwise improvement in the predictive performance of HE scores. However, no existing score achieved excellent predictive performance (c-statistics ≥0.90) in our cohort, highlighting the need for further refinement.

How to manage antivirals in critically ill patients with influenza?

BACKGROUND

Influenza is a significant cause of morbidity and mortality, particularly in critically ill patients. The availability of effective antiviral therapies is pivotal in mitigating the severity and complications associated with influenza.

OBJECTIVES

This review evaluates the antivirals available for the treatment of severe influenza in critically ill patients, focusing on the strength of recommendations and levels of evidence derived from clinical trials, observational studies, and guidelines. The aim is to provide clinicians with evidence-based insights to optimize antiviral strategies in the intensive care unit setting.

SOURCES

A comprehensive literature search was conducted using PubMed, Embase, and Cochrane Library databases for studies published up to January 2025. Keywords included "antiviral therapy," "influenza," "critically ill patients," "oseltamivir," "peramivir," "zanamivir," "lanimavir," "baloxavir," and "favipiravir." Additional references were identified from the bibliographies of relevant articles.

CONTENT

The following topics are covered: antivirals available for treating influenza and evidence supporting their use in critically ill patients, pharmacokinetic issues of enteral oseltamivir administration in critically ill patients, and neuraminidase inhibitors resistance.

IMPLICATIONS

Neuraminidase inhibitors constitute the vast majority of antivirals currently prescribed for influenza. The most commonly prescribed neuraminidase inhibitor to date is oseltamivir. Although its efficacy in nonsevere cases of influenza is well established, the evidence for its efficacy in critically ill patients is based on less robust studies, as no randomized controlled trials have been conducted in this population. Limited data on oseltamivir pharmacokinetics is available in critically ill patients. The selection of A(H1N1)pdm09 resistant variants to oseltamivir is particularly problematic in critically ill patients hospitalized in intensive care units. Data on other antivirals, such as neuraminidase inhibitors (i.e. zanamivir, peramivir and laninamivir) or baloxavir marboxil in critically ill patients are scarce. Further research is needed to develop new drugs and assess their efficacy in critically ill patients and to better assess the effect of oseltamivir in this population.

CMPK2 promotes microglial activation through the cGAS-STING pathway in the neuroinflammatory mechanism

The activation of microglia and the resulting neuroinflammation play crucial regulatory roles in the pathogenesis and progression of neurological diseases, although the specific mechanisms remain incompletely understood. Cytidine monophosphate kinase 2 (CMPK2) is a key mitochondrial nucleotide kinase involved in cellular energy metabolism and nucleotide synthesis. Recent studies suggest that CMPK2 plays a role in microglial-mediated neuroinflammation; however, its specific impact on microglial activation remains unclear. In this study, we hypothesize that CMPK2 promotes microglial-mediated neuroinflammation by activating the cGAS-STING signaling pathway. To investigate this mechanism, we employed lipopolysaccharide (LPS)-treated microglial cells to investigate the detailed mechanisms by which CMPK2 regulates neuroinflammation. Our experimental results indicate that in the BV2 and mouse primary microglial neuroinflammation model, both CMPK2 protein and transcript levels were significantly elevated, accompanied by microglial activation phenotypes such as increased cell size, shortened processes, transformation to round or rod-like shapes, and elevated CD40 expression. Concurrently, there was an increase in pro-inflammatory cytokine levels and a decrease in anti-inflammatory cytokine levels. Further investigation revealed that in the microglial, the expression of cGAS and STING was elevated, along with an increase in oxidative products and inflammatory responses. CMA stimulation further intensified these changes, while cGAS knockdown mitigated them. Finally, we demonstrated that cGAS knockdown inhibited the oxidative stress, cell activation-related changes, and neuroinflammatory responses induced by CMPK2 overexpression in the BV2 neuroinflammation model. Molecular docking experiments showed that CMPK2 stably binds to cGAS at the protein level. These findings suggest that the cGAS-STING pathway mediates CMPK2-induced microglial activation. In summary, our study demonstrates that LPS-induced CMPK2 overactivity promotes microglial activation and neuroinflammatory through the cGAS-STING pathway.

A transfer triage tool for COVID-19 mass critical care surges

The objective of this study is to develop and validate a predictive model for mortality among severe COVID-19 patients who are candidates for inter-hospital transfer. A multicenter prospective observational study was conducted between 1 January 2021 and 30 April 2021 (third and fourth pandemic waves) in regional coordination centers of the Emergency Medical Services of eight Spanish autonomous communities. Hospitalized patients with severe COVID-19 transferred to other hospitals were included. Clinical variables from the initial evaluation, the triage score, and in-hospital mortality rates were collected. A Lasso-type regression analysis was performed to fit the mortality predictive model and its performance was evaluated by a leave-one-out cross-validation. Subsequently, the regional mass triage (MATER) score was created. 1,018 transferred patients were included, with a mean age of 62.3 years (SD 12), of whom 65.1% were male and 89.6% were admitted to an Intensive Care Unit. In-hospital mortality was 23.0%. The MATER score included six variables and presented good discrimination ability with an area under the curve of 0.79 (95% CI 0.77-0.81) and a good calibration with a Brier score of 0.135. The MATER score successfully predicted the mortality rate of severe COVID-19 patients and can be helpful in decision-making for triage and transfer prioritization in mass critical care surges.

Role of the endothelial cell glycocalyx in sepsis-induced acute kidney injury

Sepsis-induced acute kidney injury (S-AKI) is a common complication of sepsis. It occurs at high incidence and is associated with a high level of mortality in the intensive care unit (ICU). The pathophysiologic mechanisms underlying S-AKI are complex, and include renal vascular endothelial cell dysfunction. The endothelial glycocalyx (EG) is a polysaccharide/protein complex located on the cell membrane at the luminal surface of vascular endothelial cells that has anti-inflammatory, anti-thrombotic, and endothelial protective effects. Recent studies have shown that glycocalyx damage plays a causal role in S-AKI progression. In this review, we first describe the structure, location, and basic function of the EG. Second, we analyze the underlying mechanisms of EG degradation in sepsis and S-AKI. Finally, we provide a summary of the potential therapeutic strategies that target the EG.

Intermediate Care Units in Internal Medicine

BACKGROUND

Intermediate Care Units (ImCU) have been historically described as an intermediate level of care between standard wards and intensive care units (ICU), and general medical ImCUs have evolved as specifically addressed to high care medical patients. The objective of this study is to explore designs, appropriateness criteria, and quality of care of general medical ImCUs.

METHODS

a comprehensive literature search was performed in electronic database (PubMed/Medline, Embase, Cochrane and Web of Science) up to July 30th 2024 and data about general medical ImCU denominations, settings, processes and outcomes were extracted.

RESULTS

34 studies were included in systematic analyses, the more used nomenclature was ImCU (70.6 %), followed by High Dependency Unit (20.6 %). The median number of beds was 8 [4-11], the nurse-to-patients ratio 1:3.1, and internists involved in comanagement in 40.0 %. Either a step-up from standard wards or a step-down from ICUs role were reported, with a median of 50.8 % [26.2-71.0] of patients directly admitted from Emergency Departments. The main distinctive activities were continuous monitoring and non-invasive ventilation. The median ICU transfer rate was 8.0 % [5.6-12.3], while in-ImCU and in-hospital mortality were 6.2 % [3.6-8.3] and 14.0 % [8.7-19.1], respectively.

CONCLUSIONS

general medical ImCUs are being increasingly recognized as the appropriate setting for high care medical patients but present to date a wide variability of formats. Activity-based admission criteria tailored on each hospital reality could be a process model for adequate patient flow, and quality of care key indicators should consider the functional general medical ImCU role in hospital macro-systems.