Development of a patient-oriented transfer tool for transition from the intensive care unit to the ward: a mixed methods study

PURPOSE

The use of patient/family-centred written summaries to supplement verbal information may be useful to improve knowledge and reduce anxiety related to patient transfer from the intensive care unit (ICU) to a hospital ward. We aimed to identify essential elements to include in an ICU-specific patient-oriented discharge summary tool (PODS-ICU).

METHODS

We conducted a mixed methods study. Participants were ICU patients who were transitioning to a hospital ward and clinicians. We used a validated questionnaire to measure the relocation stress of patients, and standardized questions to qualitatively explore patients' needs during the transition, as well as perspectives of clinician stakeholders. Inductive thematic analysis was used for the qualitative analysis.

RESULTS

We recruited 22 participants, including ten patients and 12 clinician stakeholders. Of ten patients, 50-100% reported positive experiences during the transition and 10-30% reported negative experiences. From all participants' perspectives, we identified the following essential elements for the PODS-ICU: the reason for transition, a summary of the ICU course, a clinical update, destination ward details, medication reconciliation, a future care plan, and the planned follow-up by the ICU outreach team. Family presence and earlier notification of an upcoming transfer were identified as support needs to help patients prepare mentally and reduce transfer anxiety. Moreover, using positive communication with patients when providing transfer details and using the brief standardized transfer tool were recommended to improve transition care.

CONCLUSIONS

We identified informational gaps in patient and family knowledge at the time of transfer from the ICU to a ward, which informed essential elements for the PODS-ICU. The PODS-ICU may reduce transfer anxiety and improve care during the transition from the ICU.

Vascular endothelial cell injury: causes, molecular mechanisms, and treatments

Vascular endothelial cells form a single layer of flat cells that line the inner surface of blood vessels, extending from large vessels to the microvasculature of various organs. These cells are crucial metabolic and endocrine components of the body, playing vital roles in maintaining circulatory stability, regulating vascular tone, and preventing coagulation and thrombosis. Endothelial cell injury is regarded as a pivotal initiating factor in the pathogenesis of various diseases, triggered by multiple factors, including infection, inflammation, and hemodynamic changes, which significantly compromise vascular integrity and function. This review examines the causes, underlying molecular mechanisms, and potential therapeutic approaches for endothelial cell injury, focusing specifically on endothelial damage in cardiac ischemia/reperfusion (I/R) injury, sepsis, and diabetes. It delves into the intricate signaling pathways involved in endothelial cell injury, emphasizing the roles of oxidative stress, mitochondrial dysfunction, inflammatory mediators, and barrier damage. Current treatment strategies-ranging from pharmacological interventions to regenerative approaches and lifestyle modifications-face ongoing challenges and limitations. Overall, this review highlights the importance of understanding endothelial cell injury within the context of various diseases and the necessity for innovative therapeutic methods to improve patient outcomes.

Can utilization of the venous-to-arterial carbon dioxide difference improve patient outcomes in cardiogenic shock? A narrative review

Cardiogenic shock (CS) is a critical condition with high mortality, characterized by reduced cardiac output (CO) and tissue hypoperfusion, despite advancements in treatment. Traditional hemodynamic markers like CO measurements, monitoring of mixed venous oxygen saturation (SvO₂) and lactate levels have limitations, particularly in detecting microcirculatory dysfunction. The venous-to-arterial carbon dioxide tension difference (V-A PCO₂ gap, also known as P(V-A)CO2 and delta PCO2 or ∆PCO2) has been established as a sensitive marker of tissue perfusion and CO adequacy in septic shock but lacks extensive exploration in CS. This narrative review evaluates the possible uses of V-A PCO₂ gap in contemporary management of CS. Based on the available literature, it elucidates how the V-A PCO2 gap may offer valuable insight into tissue perfusion and CO adequacy in patients with CS. Elevated V-A PCO₂ gaps may reflect impaired clearance of CO₂ due to reduced CO and tissue hypoxia, serving as a reliable early indicator of circulatory failure. Integrating V-A PCO₂ gap monitoring into contemporary hemodynamic assessments holds potential to improve clinical decision-making, enabling more timely interventions and better stratification of patients at risk of deterioration. The sparse evidence suggests an association between elevated V-A PCO₂ gaps and poor outcomes in cardiac patients, including increased mortality and prolonged ventilation needs. Further research is needed to validate the use of this marker in CS and explore its potential to enhance treatment protocols by providing a more nuanced understanding of tissue-level perfusion, especially when macrocirculatory function appears normalized.

Affordable Implementation of a Point-of-Care Ultrasound Program in a Large Tertiary Neonatal Intensive Care Unit to Assess Umbilical Venous Catheter Tips and Aid Central Placement

OBJECTIVE

 This study aimed to implement a point-of-care ultrasound (POCUS) program into a large neonatal intensive care unit (NICU) to enhance care by improving (1) umbilical venous catheter (UVC) tip identification and (2) central placement.

STUDY DESIGN

 A POCUS program was established with core providers who received training from external and internal experts. A prospective study (n = 94) compared the accuracy of UVC identification between neonatology-performed ultrasound (NeoUS) and X-ray relative to a referent of radiology-interpreted ultrasound. Finally, an ultrasound-guided UVC insertion protocol was introduced to rescue noncentral traditionally placed catheters (n = 37).

RESULTS

 Program implementation trained six providers for a total cost of approximately $10,500 USD. NeoUS was more accurate than X-ray at identifying UVC location (81.9 vs. 60.6%) with improved sensitivity and specificity (80.0 and 84.6 vs. 52.5 and 66.7%, respectively). POCUS guidance was able to rescue 89.2% of catheters that were originally noncentral.

CONCLUSION

 POCUS implementation in a large NICU is feasible, affordable, and can improve quality of care.

KEY POINTS

· POCUS implementation is feasible and affordable.. · POCUS is more accurate than X-ray at monitoring UVCs.. · Central UVC placement can be increased with POCUS..

Atypical Presentation of Tumor Lysis Syndrome Complicated by Rasburicase-Induced Methemoglobinemia

Tumor lysis syndrome (TLS) is a life-threatening metabolic disorder caused by the rapid breakdown of malignant cells, usually associated with chemotherapy treatment. It can lead to electrolyte imbalances, such as hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia. These disturbances can lead to complications, including acute renal failure, cardiac arrhythmias, and seizures. TLS typically presents in patients with hematologic malignancies; however, there has been an increase in cases in the context of solid tumors with comorbid conditions, bulky tumors, or dehydration. This report presents a case of TLS in an approximately 65-year-old female with stage IV squamous cell carcinoma of the cervix who developed acute kidney injury, lactic acidosis, and hyperuricemia following chemotherapy with docetaxel. Despite the absence of classic electrolyte abnormalities, her clinical decompensation raised suspicions of TLS. The patient was treated with rasburicase for hyperuricemia, from which she developed methemoglobinemia, a rare complication in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency. This case highlights the challenges in diagnosing atypical presentation of TLS in solid tumor patients. It also emphasizes the rare but serious complications of raburicase in G6PD-deficient individuals, such as methemoglobinemia. Further research into TLS in solid tumors and the role of G6PD screening in preventing adverse drug reactions in at-risk populations would be beneficial in these cases. Early recognition, rapid testing, and individualized treatment strategies are essential for patient care in these complex clinical scenarios.

Advancing Neurocritical Care with Artificial Intelligence and Machine Learning: The Promise, Practicalities, and Pitfalls ahead

Expansion of artificial intelligence (AI) in the field of medicine is changing the paradigm of clinical practice at a rapid pace. Incorporation of AI in medicine offers new tools as well as challenges, and physicians and learners need to adapt to assimilate AI into practice and education. AI can expedite early diagnosis and intervention with real-time multimodal monitoring. AI assistants can decrease the clerical burden of heath care improving the productivity of work force while mitigating burnout. There are still no regulatory parameters for use of AI and regulatory framework is needed for the implementation of AI systems in medicine to ensure transparency, accountability, and equitable access.

Nomophobia: a challenge among healthcare professionals in Africa

OBJECTIVES

This study delves into implementing Global Provider's phone-lessness phobia (Global 3-P Study) within the healthcare sector in Africa through a multinational, cross-sectional, web-based survey from April 1st to 30 June 2023.

METHODS

Utilizing a modified Nomophobia Questionnaire (NMP-Q), the research explores four dimensions of nomophobia: the inability to communicate, loss of connectedness, difficulty accessing information, and sacrificing convenience. The Global Remote Research Scholars Program (GRRSP) conducted the study, employing a 'snowball technique' for survey dissemination.

RESULTS

A total of 1636 responses were collected from healthcare professionals in Africa, predominantly aged 26-45, with a majority identifying as Black-African (86.5%) and residing mainly in Kenya (61.6%). The survey revealed a higher prevalence of Android smartphone users (71.4%) than Apple iOS (25.6%). Participants reported spending substantial time on personal (3.1-5 hours) and work-related (up to 3 hours) smartphone activities. A significant portion of respondents felt uncomfortable (74.3%), annoyed (72.0%), and nervous (61.4%) at the prospect of not having constant smartphone access to information. Concerns about disruptions to smartphone connections, such as running out of battery or data, were prevalent among participants. Analysis of nomophobia levels revealed that 46.9% experienced moderate Nomophobia Level I and 41.1% reported severe levels, while Nomophobia Level II was reported by 51.8% with moderate levels and 37.2% with severe levels. Comparative analysis based on gender and age groups showed statistically significant differences. Males exhibited lower severity levels of nomophobia compared to females, and the 36-45 age group reported the highest prevalence of severe nomophobia.

CONCLUSION

This study highlights the significant impact of nomophobia among healthcare professionals in Africa, indicating a need for interventions to mitigate its effects and promote healthy smartphone habits in this critical sector.

Health-Related Quality of Life Among Patients Who Have Survived an Episode of Sepsis in the United States: A Systematic Review

INTRODUCTION

Sepsis is a serious condition that may lead to death or profoundly affect the well-being of those who survive. The aim of this systematic review was to identify and summarize evidence on the impact of all-cause sepsis on health-related quality of life (HRQoL), physical, cognitive, and psychological outcomes among sepsis survivors in the USA.

METHODS

Studies assessing HRQoL, physical, cognitive, and psychological outcomes in patients who survived an episode of sepsis and published from January 1, 2010, to September 30, 2023, were systematically identified through EMBASE, MEDLINE, and MEDLINE In-Process databases, as well as through gray literature.

RESULTS

Of 2885 records identified, 7 studies (7 publications; N = 180,592 participants) met the eligibility criteria for inclusion in this review. Studies examined the effects of sepsis on the following outcomes of interest: HRQoL (4 studies), physical functioning (5 studies), cognitive status (3 studies), and psychological well-being (3 studies). After 12 months, sepsis survivors who developed chronic critical illness (N = 63) had significantly poorer HRQoL as measured by EuroQoL 5-dimensional (EQ-5D) questionnaire mean utility index score and Short Form 36-item (SF-36) physical and mental summary scores compared with patients who rapidly recovered (N = 110). Among patients admitted to a skilled nursing facility post-sepsis (N = 66,540), 34% and 72.5% had severe or very severe cognitive impairment and dependence to perform activities of daily living, respectively. Significant increase in moderate-to-severe cognitive impairment among severe sepsis survivors (N = 623) before and after sepsis was reported (median 0.9 [IQR: 0.4, 1.4] years; 6.1% and 16.7%, respectively [P < 0.001]). Substantial depression and anxiety symptoms were frequently observed post-sepsis, but with limited evidence for increased burden as assessed by specific psychological measures.

CONCLUSION

These findings underscore the profound negative impacts of sepsis on patients' HRQoL, ability to perform activities of daily living, and cognitive abilities.

Predictive value analysis of albumin-related inflammatory markers for short-term outcomes in patients with In-hospital cardiac arrest

OBJECTIVE

This study investigated the predictive value of albumin-related inflammatory markers for short-term outcomes in in-hospital cardiac arrest (IHCA) patients.

METHODS

A linear mixed model investigated the dynamic changes of markers within 72 hours after return of spontaneous circulation (ROSC). Time-Dependent COX regression explored the predictive value. Mediation analysis quantified the association of markers with organ dysfunctions and adverse outcomes.

RESULTS

Prognostic Nutritional Index (PNI) and RDW-Albumin Ratio (RAR) slightly changed (p > 0.05). Procalcitonin-Albumin Ratio (PAR1) initially increased and then slowly decreased. Neutrophil-Albumin Ratio (NAR) and Platelet-Albumin Ratio (PAR2) decreased slightly during 24-48 hours (all p<0.05). PNI (HR = 1.646, 95%CI (1.033,2.623)), PAR1 (HR = 1.69, 95%CI (1.057,2.701)), RAR (HR = 1.752,95%CI (1.103,2.783)) and NAR (HR = 1.724,95%CI (1.078,2.759)) were independently associated with in-hospital mortality. PNI (PM = 45.64%, 95%CI (17.05%,87.02%)), RAR (PM = 45.07%,95%CI (14.59%,93.70%)) and NAR (PM = 46.23%,95%CI (14.59%,93.70%)) indirectly influenced in-hospital mortality by increasing SOFA (central) scores. PNI (PM = 21.75%, 95%CI(0.67%,67.75%)) may also indirectly influenced outcome by increasing SOFA (renal) scores (all p < 0.05).

CONCLUSIONS

Within 72 hours after ROSC, albumin-related inflammatory markers (PNI, PAR1, RAR, and NAR) were identified as potential predictors of short-term prognosis in IHCA patients. They may mediate the adverse outcomes of patients by causing damages to the central nervous system and renal function.

Effect of a Machine Learning-Derived Early Warning Tool With Treatment Protocol on Hypotension During Cardiac Surgery and ICU Stay: The Hypotension Prediction 2 (HYPE-2) Randomized Clinical Trial

OBJECTIVES

Cardiac surgery is associated with perioperative complications, some of which might be attributable to hypotension. The Hypotension Prediction Index (HPI), a machine-learning-derived early warning tool for hypotension, has only been evaluated in noncardiac surgery. We investigated whether using HPI with diagnostic guidance reduced hypotension during cardiac surgery and in the ICU.

DESIGN

Randomized clinical trial conducted between May 2021 and February 2023.

SETTING

Single-center study conducted in an academic hospital in the Netherlands.

PATIENTS

Adults undergoing elective on-pump coronary artery bypass grafting, with or without single heart valve surgery, were enrolled if a mean arterial pressure (MAP) greater than or equal to 65 mm Hg was targeted during the surgical off-pump phases and ICU stay. After eligibility assessment, 142 of 162 patients approached gave informed consent for participation.

INTERVENTIONS

Patients randomized 1:1 received either diagnostic guidance in addition to standard care if HPI reached greater than or equal to 75 ( n = 72) or standard care alone ( n = 70).

MEASUREMENTS AND MAIN RESULTS

The primary outcome was the severity of hypotension, measured as time-weighted average (TWA) of MAP less than 65 mm Hg. Secondary outcomes encompassed hypertension severity and intervention disparities. Of 142 patients randomized, 130 were included in the primary analysis. The HPI group showed 63% reduction in median TWA of hypotension compared with the standard care group, with a median of differences of -0.40 mm Hg (95% CI, -0.65 to -0.27; p < 0.001). In the HPI group, patients spent a median 28 minutes (95% CI, 17-44 min) less in hypotension, with a measurement duration of 322 minutes in the HPI group and 333 minutes in the standard care group. No significant differences were observed in hypertension severity, treatment choice, or fluid, vasopressors, and inotrope amounts.

CONCLUSIONS

Using HPI combined with diagnostic guidance on top of standard care significantly decreased hypotension severity in elective cardiac surgery patients compared with standard care.

Pediatric Endocrinology Education Among Trainees: A Scoping Review

INTRODUCTION

Pediatric endocrinology education is a fundamental part of all pediatric endocrinology training. Hence, understanding the current methods used for training learners on skills required and understanding methods or topics that may be underexplored could help improve the quality of training.

OBJECTIVE

This study aims to explore training and assessment strategies used in pediatric endocrinology training across medical education programs through a scoping review.

METHODS

Search strategy was developed with a librarian, and bibliographic databases (e.g., MEDLINE and EMBASE) were searched from January 2005 to July 2024. Pilot screenings ensured consistent inclusion/exclusion decisions among reviewers. Full-text articles were included if they were related to pediatric endocrinology education and focused on medical learners.

RESULTS

We included 45 of 5814 sources of evidence for data extraction. Majority focused on knowledge of Type 1 and Type 2 diabetes and diabetes ketoacidosis (N = 18), followed by differences in sex development and pubertal assessment (N = 12). The most frequently used training method was through didactics. Additionally, the most frequently used assessment measures included knowledge tests (N = 25). Also, a limited number of studies targeted obesity (N = 2), gender care (N = 3), thyroid (N = 1) and hypoglycaemia (N = 1), and no studies targeted common topics such as bone health and adrenal insufficiency.

CONCLUSION

This review reveals the current emphasis on diabetes-related topics and traditional teaching in pediatric endocrinology education. It suggests a need for more innovative methods, like simulation-based learning and varied assessment techniques, to better equip trainees. Addressing these gaps can improve trainee confidence, patient care, and health outcomes for children with endocrine disorders.

Evaluation of the Performance of Various Diagnostic Modalities Available for the Detection of Scrub Typhus in Acute Undifferentiated Febrile Illness (AUFI) Cases at a Teaching Hospital in North Chhattisgarh, India

INTRODUCTION

Due to the lack of adequate data on the effectiveness of diagnostic methods and the ambiguous clinical symptoms that overlap with other febrile illnesses, diagnosing scrub typhus is difficult. This study aims to compare the accuracy of various investigations required for the diagnosis of scrub typhus like immunoglobulin G/immunoglobulin M (IgG/IgM) rapid test, IgM enzyme-linked immunosorbent assay (ELISA), and real-time polymerase chain reaction (RT-PCR) from a patient's serum.

METHODS

This is a prospective study that includes all clinically suspected patients who visited the Outpatient Department (OPD) of Medicine and were admitted to the Medicine wards and Intensive Care Units of Rajmata Shrimati Devendra Kumari Singhdeo Government Medical College, Ambikapur, Chhattisgarh, India. The patients' samples were tested initially using the IgG/IgM rapid test, further confirmed by ELISA, and then subjected to RT-PCR for final confirmation.

RESULTS

A total of 1,620 cases of acute undifferentiated febrile illness were tested, of which 82 tested positive for scrub typhus IgM rapid test. These 82 cases were further tested for confirmation using IgM ELISA, which showed 110 positive results. Additionally, RT-PCR was applied to all 1,620 samples using the DIAGsure Tropical Fever Panel Kit (3B BlackBio Dx Limited, Bhopal, India), resulting in 98 samples testing positive for scrub typhus. Both the ELISA and the rapid diagnostic test offer high capacity for discrimination, with sensitivity and specificity of 92.40%, 93.18%, and 99.20%, 98.17%, respectively (10.9% of cases came positive in serology which was negative in RT-PCR). It can be due to its nonspecific binding with antibodies of other febrile illnesses such as malaria, enteric fever, pulmonary tuberculosis, leptospirosis, etc. Conclusion: RT-PCR has shown excellent results with a sensitivity of >95% and specificity of >99%. Given its high sensitivity and specificity, along with clinical findings, RT-PCR is highly effective in detecting scrub typhus, especially for diagnosing early stages of the disease in cases of acute febrile illness with a duration of less than seven days. In reference labs, RT-PCR is the primary method for confirmation. This paper offers a thorough assessment of all the diagnostic tests for scrub typhus that are now accessible in a setting with limited resources, such as our north Chhattisgarh region.

Biosensing for rapid detection of MDR, XDR and PDR bacteria

The emergence of multidrug-resistant (MDR), extensively drug-resistant (XDR), and pandrug-resistant (PDR) bacteria poses a significant threat to global public health, complicating the management of infectious diseases and increasing morbidity and mortality rates. Rapid and sensitive detection of these resistant pathogens is crucial for effective treatment and infection control. This manuscript provides a comprehensive overview of various biosensor technologies developed for the rapid identification and quantification of MDR and XDR bacteria. We discuss the principles of operation, sensitivity, specificity, and practical applications of different biosensing platforms, including electrochemical, optical, and piezoelectric sensors. Additionally, we explore recent advancements in nanomaterials and microfluidics that enhance biosensor performance and enable point-of-care testing. The manuscript also addresses the challenges faced in the implementation of these technologies in clinical settings, such as regulatory hurdles and the need for standardization. A systematic literature review was conducted to identify relevant studies. Databases utilized include PubMed and Scopus, covering the time frame from 2015 to 2024. The literature screening criteria focused on the inclusion of only clinically validated studies to ensure the reliability and applicability of the findings. By highlighting the potential of biosensors to revolutionize the detection of drug-resistant bacteria, this work aims to inform researchers, clinicians, and policymakers about the critical role of innovative diagnostic tools in combating antibiotic resistance and improving patient outcomes.

The role of atrial fibrillation in vascular cognitive impairment and dementia: epidemiology, pathophysiology, and preventive strategies

The aging population in Europe faces a substantial burden from dementia, with vascular cognitive impairment and dementia (VCID) being a preventable cause. Atrial fibrillation (AF), a common cardiac arrhythmia, increases the risk of VCID through mechanisms such as thromboembolism, cerebral hypoperfusion, and inflammation. This review explores the epidemiology, pathophysiology, and preventive strategies for AF-related VCID. Epidemiological data indicate that AF prevalence rises with age, affecting up to 12% of individuals over 80. Neuroimaging studies reveal chronic brain changes in AF patients, including strokes, lacunar strokes, white matter hyperintensities (WMHs), and cerebral microbleeds (CMHs), while cognitive assessments show impairments in memory, executive function, and attention. The COVID-19 pandemic has exacerbated the underdiagnosis of AF, leading to an increase in undiagnosed strokes and cognitive impairment. Many elderly individuals did not seek medical care due to fear of exposure, resulting in delayed diagnoses. Additionally, reduced family supervision during the pandemic contributed to missed opportunities for early detection of AF and related complications. Emerging evidence suggests that long COVID may also elevate the risk of AF, further complicating the management of this condition. This review underscores the importance of early detection and comprehensive management of AF to mitigate cognitive decline. Preventive measures, including public awareness campaigns, patient education, and the use of smart devices for early detection, are crucial. Anticoagulation therapy, rate and rhythm control, and addressing comorbid conditions are essential therapeutic strategies. Recognizing and addressing the cardiovascular and cognitive impacts of AF, especially in the context of the COVID-19 pandemic, is essential for advancing public health.

Mean Platelet Volume-to-Platelet Count Ratio (MPR) in Acute Exacerbations of Idiopathic Pulmonary Fibrosis: A Novel Biomarker for ICU Mortality

Background and Objectives: Acute exacerbation of idiopathic pulmonary fibrosis (IPF-AE) often results in severe respiratory distress requiring treatment in the intensive care unit and has a high mortality rate. Identifying prognostic markers and assessing disease severity are crucial for clinicians to gain detailed insights. The mean platelet volume-to-platelet count ratio (MPR) is an inflammatory marker commonly used in malignancies. This study aimed to evaluate MPR and other factors affecting mortality in patients with IPF-AE who were monitored in the intensive care unit (ICU). Materials and Methods: This retrospective study was conducted on patients monitored in the ICU for IPF-AE between 2017 and 2023. Demographic characteristics, vital signs, laboratory and imaging findings, and administered treatments were reviewed. MPR was calculated by dividing the mean platelet volume by the platelet count. The primary endpoint was defined as 1-month in-hospital mortality. Results: A total of 59 patients monitored in the ICU for IPF-AE were included in the study. The mean age of the patients was 62.75 years, and 81.4% of the participants were male. During the 30-day follow-up period, 62.7% of the patients died. The need for invasive mechanical ventilation (IMV) was significantly associated with increased mortality (p < 0.001). The optimal cutoff value for MPR was determined to be 0.033, with a sensitivity of 83.7% and specificity of 63.64%, indicating its predictive value for mortality (AUC: 0.764; 95% CI: 0.635-0.864; p < 0.001). Conclusions: In this study, the need for IMV emerged as a critical parameter in predicting mortality in patients with IPF-AE. Additionally, the use of the MPR as a prognostic biomarker may offer a novel approach in the management of IPF patients. These findings could contribute to the development of strategies aimed at early intervention in IPF patients. Further studies with larger sample sizes are needed to validate these results. This study has demonstrated that MPR is a significant prognostic biomarker for predicting mortality in patients with IPF-AE who are managed in the intensive care unit. The potential use of MPR as a biomarker in clinical decision-making may provide new approaches to the management of IPF patients. Additionally, the need for IMV in IPF-AE emerges as a critical parameter for predicting mortality. These findings may contribute to the development of early intervention strategies for IPF patients. Further studies with larger cohorts are needed to validate these results.

Using a clinical decision support system to reduce excess driving pressure: the ALARM trial

BACKGROUND

Patients at need for ventilation often are at risk of acute respiratory distress syndrome (ARDS). Although lung-protective ventilation strategies, including low driving pressure settings, are well known to improve outcomes, clinical practice often diverges from these strategies. A clinical decision support (CDS) system can improve adherence to current guidelines; moreover, the potential of a CDS to enhance adherence can possibly be further increased by combination with a nudge type intervention.

METHODS

A prospective cohort trial was conducted in patients at risk of ARDS admitted to an intensive care unit (ICU). Patients were assigned to control or intervention by their date of admission: First, the control group was included without changing anything in clinical practice. Next, the CDS was activated showing an alert in the patient data management system if driving pressure exceeded recommended values; additionally, data on the performance of the wards were sent to the healthcare professionals as the nudge intervention. The main hypothesis was that this combined intervention would lead to a significant decrease in excess driving pressure.

RESULTS

The 472 included patients (230 in the control group and 242 in the intervention group) consisted of 33% females. The median age was 64 years; median Sequential Organ Failure Assessment score was 8. There was a significant reduction in excess driving pressure in the augmented ventilation modes (0.28 ± 0.67 mbar vs. 0.14 ± 0.45 mbar, p = 0.012) but not the controlled mode (0.37 ± 0.83 mbar vs. 0.32 ± 0.8 mbar, p = 0.53). However, there was no significant difference between groups in mechanical power, the number of ventilator-free days, or the percentage of patients showing progression to ARDS. Although there was no difference in progression to ARDS, 28-day mortality was higher in the intervention group. Notably, the mean overall driving pressure across both groups was low (12.02 mbar ± 2.77).

CONCLUSIONS

In a population at risk of ARDS, a combined intervention of a clinical decision support system and a nudge intervention was shown to reduce the excessive driving pressure above 15 mbar in augmented but not in controlled modes of ventilation.

Self-Perception of Voice at Different Moments and Hospitalization for COVID-19: The Influence of Sociodemographic and Clinical Variables

PURPOSE

This study aimed to compare the self-perception of voice at different times and the influence of age, number of infections, underlying diseases, and occupational voice use among individuals with Coronavirus Disease 2019 (COVID-19), with or without a history of hospitalization.

METHODS

Data were collected from adults and older adults with COVID-19, treated at a Brazilian Military Hospital between April 2020 and May 2023. The questionnaire was sent by email and a messaging application. The data were analyzed by comparing self-perception of voice at different times and the study variables in the hospitalized and nonhospitalized groups.

RESULTS

The sample comprised 101 individuals. Self-perception of voice quality worsened during COVID-19 in all three age groups, regardless of hospitalization history. Individuals with more than one infection had worse vocal self-perception during COVID-19, regardless of hospitalization. The worsening was greater among individuals with allergies and hearing loss. Arterial hypertension was associated with worsening after COVID-19 in the nonhospitalized group and with better self-perception before COVID-19 in hospitalized patients. Reflux was associated with hospitalized patients and worse self-perception of vocal quality at all times. Hospitalized occupational voice users had greater vocal quality improvement after COVID-19.

CONCLUSIONS

Regardless of hospitalization and age group, participants self-perceived voice worsening during COVID-19, with a greater decline among hospitalized patients, and a slower recovery among hospitalized older people. More than one infection negatively impacted voice self-perception during COVID-19, and having one infection and no hospitalization was more promising for the voice. Allergies, hearing loss, hypertension, and reflux had an impact on voice self-perception during and/or after COVID-19. Hospitalized occupational voice users had greater vocal quality improvement, whereas nonhospitalized occupational voice users improved more slowly.

Prediction of posthepatectomy liver failure in patients with hepatocellular carcinoma through ultrasound elastography

In this article, we comment on the article by Cheng et al published in recently. Posthepatectomy liver failure (PHLF) remains a leading cause of hepatectomy-related mortality and can be evaluated according to liver reserve function. Liver stiffness (LS) measured by ultrasonic elastography and spleen area demonstrate a strong correlation with hepatic proliferation, fibrosis, and portal vein congestion, thus indirectly reflecting liver reserve function. This article highlights a meticulous study aimed at investigating the potential of two-dimensional shear wave elastography in assessing LS, as well as its integration with spleen area, surgical factors, and laboratory indicators, for predicting the risk of PHLF in hepatocellular carcinoma patients. In this article, we discussed the non-invasive elastography modality by ultrasound and magnetic resonance imaging to assess LS. Based on literature data, we subsequently suggested that several risk factors may contribute to PHLF, including excessive intrahepatic neutrophil accumulation, the formation of neutrophil extracellular traps, end-stage liver disease scores, and albumin-bilirubin scores. Therefore, a more comprehensive study incorporating detailed information requires further investigation.

Lower red blood cell count is a risk factor for higher D-dimer level in patients with spinal cord injury: A five year retrospective cross-sectional study

OBJECTIVES

This study aims to elucidate the relationship between red blood cell (RBC) count and D-dimer levels in patients with spinal cord injury, with the goal of identifying potential therapeutic targets for minimizing D-dimer levels.

STUDY DESIGN

An observational, retrospective, cross-sectional, single center study.

SETTING

Individuals with SCI (576 cases) admitted to a rehabilitation medicine department.

OUTCOME MEASURES

After exclusions, we divided the participants (n = 308) into two groups based on their D-dimer levels: Group 1 (≤0.5  mg/L, n = 64) and Group 2 (>0.5  mg/L, n = 244). Key variables such as deep vein thrombosis (DVT), anticoagulant therapy, pulmonary infection, injury characteristics, and hematological parameters were analyzed for their association with RBC counts and D-dimer levels.

RESULTS

DVT and anticoagulant therapy emerged as significant covariates. A comprehensive analysis identified a negative linear correlation between RBC counts and D-dimer levels, markedly more pronounced in Group 2. For every 1.00 × 1012/L increase in RBC, D-dimer levels decreased by 1.93  mg/L in Group 2, compared to a 0.02  mg/L decrease in Group 1.

CONCLUSIONS

Higher RBC counts might be associated with lower D-dimer levels in patients with SCI, especially in those with higher initial D-dimer levels. This association highlights a potential therapeutic focus on managing RBC counts to decrease D-dimer level, which may mitigate the risk of DVT formation in patients with SCI.

Point-of-Care Ultrasound in Nephrology: Beyond Kidney Ultrasound

Point-of-care ultrasound (POCUS) has increasingly become an integral part of clinical practice, particularly in nephrology, where its use extends beyond renal assessment to include multi-organ evaluations. Despite challenges such as limited ultrasound training and equipment access, especially in low- and middle-income countries, the adoption of POCUS is steadily rising. This narrative review explores the growing role of multi-organ POCUS in nephrology, with applications ranging from the assessment of congestion phenotypes, cardiorenal syndrome, and hemodynamic acute kidney injury (AKI) to the evaluation of arteriovenous fistulas and electrolyte disorders. In nephrology, POCUS enhances clinical decision making by enabling rapid, bedside evaluations of fluid status, cardiac function, and arteriovenous access. Studies have demonstrated its utility in diagnosing and managing complications such as heart failure, cirrhosis, and volume overload in end-stage renal disease. Additionally, POCUS has proven valuable in assessing hemodynamic alterations that contribute to AKI, particularly in patients with heart failure, cirrhosis, and systemic congestion. This review highlights how integrating ultrasound techniques, including lung ultrasound, venous Doppler, and focused cardiac ultrasound, can guide fluid management and improve patient outcomes. With advancements in ultrasound technology, particularly affordable handheld devices, and the expansion of targeted training programs, the potential for POCUS to become a global standard tool in nephrology continues to grow, enabling improved care in diverse clinical settings.

Reply to Riva et al. Comment on "Gaspari et al. Blood Purification in Hepatic Dysfunction after Liver Transplant or Extensive Hepatectomy: Far from the Best-Case Scenarios. J. Clin. Med. 2024, 13, 2853"

We sincerely appreciate the authors' comments [...].

Unravelling neuroregenerative and neuroprotective roles of Wnt/β-catenin pathway in ischemic stroke: Insights into molecular mechanisms

Stroke is a serious condition often resulting in mortality or long-term disability, causing cognitive, memory, and motor impairments. A reduction in cerebral blood flow below critical levels defines the ischemic core and penumbra: the core undergoes irreversible damage, while the penumbra remains viable but functionally impaired. This functional impairment activates complex cell signaling pathways that determine cell survival or death, making the penumbra a key target for therapeutic interventions to prevent further damage. The Wnt/β-catenin (WβC) signaling pathway has emerged as a potential neuroprotective mechanism, promoting neurogenesis, angiogenesis, neuronal connectivity, and maintaining blood-brain barrier integrity after stroke. Activation of the WβC pathway also mitigates oxidative stress, inflammation, and apoptosis in ischemic regions, enhancing its neuroprotective effects. However, the overexpression of GSK3β and DKK1, or the presence of their agonists, can counteract these benefits. This review explores the therapeutic potential of WβC signaling, highlighting the effects of pharmacological modulation through antagonists, agonists, synthetic chemicals, natural products, stem cells, and macromolecules in preclinical models of ischemic stroke. While preclinical evidence supports the benefits of WβC activation, its role in human stroke requires further investigation. Additionally, the review discusses the potential adverse effects of prolonged WβC activation and suggests strategies to mitigate them. Overall, WβC signaling holds promise as a therapeutic target, offering insights into stroke pathophysiology and informing the development of novel treatment strategies.

Enhancing trauma cardiopulmonary resuscitation simulation training with the use of virtual reality (Trauma SimVR): Protocol for a randomized controlled trial

BACKGROUND

With the increasing availability and use of digital tools such as virtual reality in medical education, there is a need to evaluate their impact on clinical performance and decision-making among healthcare professionals. The Trauma SimVR study is investigating the efficacy of virtual reality training in the context of traumatic in-hospital cardiac arrest.

METHODS AND ANALYSIS

This study protocol (clinicaltrials.gov identifier: NCT06445764) for a single-center, prospective, randomized, controlled trial focuses on first-year residents in anesthesiology/intensive care, traumatology, and emergency medicine. The study will compare the clinical performance in a simulated scenario between participants who received virtual reality training and those who received traditional e-learning courses for preparation. The primary endpoint is the time to a predefined intervention to treat the underlying cause of the simulated traumatic cardiac arrest. Secondary endpoints include protocol deviations, cognitive load during simulated scenarios, and the influence of gender and personality characteristics on learning outcomes. The e-learning and the virtual reality training content will be developed in collaboration with experts from various medical specialties and nursing, focusing on procedural processes, guideline adherence specific to trauma patient care, and traumatic in-hospital cardiac arrest.

RESULTS

The results of this study will provide valuable insights into the efficacy of virtual reality training, contributing to the advancement of medical education, and serve as a foundation for future research in this rapidly evolving field.

Dual Blood Purification with CytoSorb and oXiris in Managing Recurrent Septic Shock: A Case Report

BACKGROUND Extracorporeal blood purification strategies were recently developed as adjunctive treatments for sepsis. CytoSorb® is an approved medical device designed to reduce blood levels of inflammatory cytokines. The oXiris high-adsorption membrane filter is used in continuous hemofiltration adsorption. We describe the case of a 67-year-old man with recurrent septic shock, requiring treatment with antibiotics, vasopressors, inotropes, mechanical ventilation, continuous renal replacement therapy (CRRT), and adjunctive treatment with an oXiris filter and hemadsorption using the CytoSorb device. CASE REPORT A 67-year-old man was admitted to the Intensive Care Unit (ICU) with septic shock. He received antibiotics, fluids, vasopressors, and inotropes and was mechanically ventilated. Acute kidney failure was treated with CRRT. His condition improved, and he was transferred to the general ward. On day 3 in the ward, he developed a new episode of septic shock and was readmitted to ICU. Standard therapy with fluids, vasopressors, and empiric antibiotics was started. Despite treatment, his condition deteriorated dramatically. CRRT with an oXiris filter in combination with hemoadsorption using CytoSorb was started. After CRRT initiation and integration of the CytoSorb adsorber, rapid improvement in the patient's condition was observed. Daily laboratory test results showed significant decreases in procalcitonin and CRP. The patient was discharged from ICU on day 5 after initiation of CytoSorb therapy. CONCLUSIONS Although no guidelines and large clinical trial data are yet available to support the use of CytoSorb and oXiris, this report supports the findings from previous reports and small studies, that they can be considered as adjunctive treatments for patients with sepsis.

Predictors of prolonged hospitalization among geriatric trauma patients using the modified 5-Item Frailty index in a Middle Eastern trauma center: an 11-year retrospective study

BACKGROUND

Using a validated tool, we explored the prevalence, risk factors, and predictors of longer hospitalization among hospitalized geriatric patients.

METHODS

Retrospective and comparative analyses of age groups (55-64 vs. ≥ 65 years), gender, survival status, and frailty index categories were performed. The Modified 5-Item Frailty Index was assessed, and multivariable logistic regression analysis was performed to predict prolonged hospitalization (> 7 days).

RESULTS

There were 17,600 trauma hospitalizations with a mean age of 32 ± 15 years between 2010 and 2021; of them, 9.2% were geriatrics at ≥ 55-64 years (n = 935) and ≥ 65 years (n = 691). The female/male ratio was 17.5%/82.5%, and the mean injury severity score was 13 ± 9. The injury rate for age ≥ 65 was 24 per 10,000 compared to 10 per 10,000 in the younger group age (≥ 55-64). 35% of injuries occurred at home due to falls. Overall mortality was 8%, with a higher rate among males than females (9% vs. 4%). The deceased were three years older at the time of death compared to the survivors. Higher frailty grades were associated with home-related falls and head injuries. Patients 65 years or older were likely to have higher frailty scores, as indicated by higher percentages in the mFI-5. Among the older group, 25% were moderately frail, and 18% severely frail. In the younger group, 50% were frail. Higher frailty scores correlated with increased acute kidney injury, pneumonia, urinary tract infections, and longer hospital stays. Severe frailty significantly predicted longer hospitalization (odds ratio 1.83, p = 0.007).

CONCLUSION

One out of eleven trauma admissions was aged > 55. Head injury and bleeding were the leading causes of mortality in the study cohort. There was a significant decrease in the trend of geriatric trauma over the years. The modified FI-5 performs well as a predictive tool of prolonged hospitalizaion in trauma patients with different age groups.

Comment on Gaspari et al. Blood Purification in Hepatic Dysfunction after Liver Transplant or Extensive Hepatectomy: Far from the Best-Case Scenarios. J. Clin. Med. 2024, 13, 2853

We read with interest the paper entitled Case Report Blood Purification in Hepatic Dysfunction after Liver Transplant or Extensive Hepatectomy: Far from the Best-Case Scenarios, which was recently published in the Journal of Clinical Medicine [...].

Evaluation of the Effectiveness of Standard Precaution Training on Disposition of Occupational Blood Exposure Among Healthcare Trainees: A Pre-Post Intervention Study

Introduction

Blood-borne occupational exposure (OBE) is one of the major public health problem for healthcare workers globally. Effective education and training on post-exposure management and standard precautions for healthcare trainees, are important measures for reducing OBE and infection rates. The aim of this study was to evaluate the effectiveness of standard precaution training on OBE disposition for healthcare trainees, comparing the differences of "theoretical teaching" and "situational simulation" training methods.

Methods

A pre-post intervention study was conducted among 1347 healthcare trainees at a university teaching hospital located in Jining, Shandong Province from July 2023 to September 2023. Healthcare trainees who were undergoing training at the hospital from July 2020 to July 2023 were selected as the research subjects. They voluntarily participated in theoretical teaching group or situational simulation group. The two groups taught the same knowledge using different methods. Both groups were tested the same content before and after the training.

Results

The accuracy rates before and after training in different groups were 71.71% and 78.08%, respectively (P<0.001). The accuracy rate after training in the scenario simulation group (79.08%) was higher than that in the theoretical teaching group (76.60%), with a statistically significant difference (P<0.05). The accuracy rate for trainees who experienced OBE was 69.87% before training and 77.11% after training. For trainees who had not experienced OBE, the accuracy rates were 71.38% before training and 77.25% after training. The accuracy rates were higher after training compared to before training, with statistically significant differences (P<0.001).

Conclusion

Scenario simulation training exhibits significant advantages in improving accuracy due to its strong practicality, high level of participation, and timely feedback. The self-protection awareness, knowledge on OBE management, and standard precaution among healthcare trainees were enhanced through the training, and operational content can achieve better results through scenario simulation training.

Sex-Specific Differences in Sepsis Development in Polytrauma Patients Undergoing Stand-Alone Definitive Surgery

Background and Objectives: In the triaging of polytrauma, patients with less severe injuries and lower somatic stress often undergo isolated definitive orthopedic surgery without damage-control procedures. Adverse events, particularly sepsis, should be minimized. We aimed to identify sex-specific predictors for sepsis in polytrauma patients undergoing stand-alone definitive surgery. Materials and Methods: Our institutional trauma database, containing data from 3653 patients between 1996 and 2022, was filtered for polytrauma patients who underwent definitive surgery, were aged ≥16 years, and had an Injury Severity Score (ISS) ≥16. Injury and physiological parameters were documented upon admission, as well as on the first and second days thereafter. Surgical data were also recorded. All factors were evaluated for their association with sepsis development. Results: Among the 276 patients (71.1% male; mean age 45.0 years, 95% confidence interval 42.7-47.2 years; median ISS of 27, interquartile range, 20-34), the rate of sepsis was 13.8% (n = 38), with a higher incidence in males (16.7%; n = 33) than in females (6.8%; n = 5) (p = 0.026). Head and thorax injuries were more common and severe in septic males, with thorax injuries being predictive. Male patients who developed sepsis also had a higher ISS, an increased heart rate (HR), and lower pH at admission, with ISS and HR being predictive of sepsis. On the first day post-admission, septic males showed higher Base Excess and lower Prothrombin Time. Lactate levels were elevated on both the first and second days post-admission. Surgical predictors for males included less primary extremity surgeries and later secondary spine surgeries. Conclusions: Sepsis is more common in males undergoing stand-alone definitive surgery. Several factors, particularly acidosis and coagulopathy, are associated with this phenomenon. Fewer primary extremity surgeries and delayed secondary spine surgeries were also linked to a higher sepsis risk in males. These findings may help identify patients eligible for stand-alone definitive surgery and underscore the need for more data on female polytrauma patients.

Impact of hemoadsorption with CytoSorb® on meropenem and piperacillin exposure in critically ill patients in a post-CKRT setup: a single-center, retrospective data analysis

PURPOSE

CytoSorb® (CS) adsorbent is a hemoadsorption filter for extracorporeal blood purification often integrated into continuous kidney replacement therapy (CKRT). It is primarily used in critically ill patients with sepsis and related conditions, including cytokine storms and systemic inflammatory responses. Up to now, there is no evidence nor recommendation for the use of CS filters in sepsis (22). There is limited clinical data on the effect of CS on the plasma concentrations of beta-lactams. We aimed to evaluate the statistical and clinical impact of CS in a post-filter CKRT-CS setting on the plasma concentrations of the antibiotics meropenem and piperacillin in critically ill patients.

METHODS

Patients admitted to the intensive care unit (ICU) who received a prolonged infusion of piperacillin or meropenem with CS-combined CKRT were included in this retrospective analysis. TDM (therapeutic drug monitoring) plasma blood samples were collected at three different points. The differences in antibiotic concentrations between Pre, Intra, and Post were statistically compared to evaluate the total and isolated contributions of CKRT and CS to antibiotic removal. CS, CKRT and combined clearance (CL) values were calculated. The hypothesis was that the CS filter would have no clinically relevant impact on antibiotic levels.

RESULTS

207 TDM samples were taken from 24 critically ill patients requiring beta-lactam antibiotics. Among these, 129 were meropenem samples, and 78 were piperacillin samples. A decrease in both antibiotic levels was observed between Pre and Intra, and Pre and Post, and the median relative difference between was >15% (meropenem: Pre-Intra 34.8%, Pre-Post 35.8%; piperacillin: Pre-Intra 41.1%, Pre-Post 34.7%), indicating a statistically and clinically significant effect of CKRT on both antibiotic exposures. No significant difference was observed between Intra and Post indicating no clinically relevant drug removal via the CS filter. Changes in CL attributed to CS were minimal, with combined CL differing by ≤8.60% compared to CKRT clearance.

CONCLUSION

The application of CS does not appear to significantly affect plasma concentrations of meropenem and piperacillin in critically ill patients.

Reverse shock index multiplied by Glasgow coma scale (rSIG) to predict mortality in traumatic brain injury: systematic review and meta-analysis

OBJECTIVE

To determine whether the Reverse Shock Index multiplied by the Glasgow Coma Scale (rSIG) is a predictor of in-hospital mortality in patients with traumatic brain injury (TBI).

DESIGN

This is a systematic review and meta-analysis.

SETTING

A comprehensive search was conducted in five databases for studies published up to May 22, 2024, using a PECO strategy. Eight studies were identified for quantitative analysis and included in our meta-analysis.

PARTICIPANTS

The participants of the included primary studies.

INTERVENTIONS

Patients with a low rSIG as a predictor of in-hospital mortality in TBI.

MAIN VARIABLES OF INTEREST

rSIG, in-hospital mortality, TBI.

RESULTS

Our meta-analysis evaluated a total of eight observational studies encompassing 430,000 patients with TBI, observing 6,417 deaths (15%). After performing a sensitivity analysis, we found that patients with TBI and a low value of the reverse shock index multiplied by the Glasgow Coma Scale (rSIG) had a 24% higher risk of death (OR 1.24; 95% CI 1.12-1.38; I²: 96%). Furthermore, rSIG values were significantly higher in survivors compared to those who died (MD 7.72; 95% CI 1.86-13.58; I²: 99%).

Thromboelastometry-Based Profiling of Haemostatic Alterations in Neonatal Sepsis by Causative Pathogens

Background: Neonatal sepsis is a serious condition with high mortality, especially in premature and low-birth-weight neonates. This study aims to examine whether the haemostatic profile of neonates with sepsis defers depending on the type of bacteria (Gram-positive or Gram-negative), by using the method of Rotational Thromboelastometry (ROTEM). Methods: This single-centre prospective cohort study was conducted on 128 neonates with sepsis, including 95 cases caused by Gram-negative pathogens and 33 cases caused by Gram-positive bacteria. All participants were hospitalised in the Neonatal Intensive Care Unit (NICU). ROTEM parameters were compared between neonates with Gram-positive and Gram-negative infections. Results: The ROTEM parameters were found to be significantly different between neonates suffering from Gram-positive versus Gram-negative infections, with Gram-positive pathogens associated with an increased clotting potential compared to Gram-negative pathogens. This is reflected in the higher ROTEM values such as A10, α-angle, and MCF in the EXTEM and INTEM assays. Multivariant analysis showed that Gram-positive infections were linked to increased clot thickness at 10 min (coefficient: 8.9, CI: 2.8-15.0, p = 0.004), higher maximum clot stability (coefficient: 10.4, CI: 4.3-16.6, p = 0.001), and a bigger α-angle (coefficient: 8.0, CI: 2.7-13.2, p = 0.003). Similar findings were observed in the INTEM assay parameters. Conclusions: Neonatal sepsis caused by Gram-positive bacteria leads to a hypercoagulable haemostatic state, whereas neonates with sepsis caused by Gram-negative bacteria exhibit a more hypocoagulable profile and a higher incidence of haemorrhagic episodes. These findings provide valuable insights into the haemostatic disorders associated with sepsis, and may aid in developing an individualised approach for the treatment of those disorders, dependent on and adapted for the specific type of causative organism.

Spot urinary sodium-guided titration of intravenous diuretic therapy in acute heart failure: a pilot randomized controlled trial

BACKGROUND

Spot urinary sodium concentration (UNa) is advocated in guidelines to assess diuretic response and titrate dosage in acute heart failure (AHF). However, no randomized controlled trial data exist to support this approach. We performed a prospective pilot trial to investigate the feasibility of this approach.

METHODS AND RESULTS

Sixty patients with AHF (n = 30 in each arm) were randomly assigned to titration of loop diuretics for the first 48 h of admission according to UNa levels (intervention arm) or based on clinical signs and symptoms of congestion (standard care arm). Diuretic insufficiency was defined as UNa <50 mmol/L. Endpoints relating to diuretic efficacy, safety, and AHF outcomes were evaluated. UNa-guided therapy patients experienced less acute kidney injury (20% vs. 50%, P = 0.01) and a tendency towards less hypokalaemia (serum K+ <3.5 mmol, 7% vs. 27%, P = 0.04), with greater weight loss (3.3 kg vs. 2.1 kg, P = 0.01). They reported a greater reduction in the clinical congestion score (-4.7 vs. -2.6, P < 0.01) and were more likely to report marked symptom improvement (40% vs. 13.3%, P = 0.04) at 48 h. There was no difference in the length of hospital stay (median length of stay: 8 days in both groups, P = 0.98), 30-day mortality, or readmission rate.

CONCLUSION

UNa-guided titration of diuretic therapy in AHF is feasible and safer than titration based on clinical signs and symptoms of congestion, with more effective decongestion at 48 h. Further large-scale trials are needed to determine if the superiority of this approach translates into improved patient outcomes.

TRIAL REGISTRATION NUMBER

ACTRN12621000950864.

[Interpretation of "Expert recommendations for the prevention of common respiratory viral infections in neonates": problems faced by respiratory syncytial virus infection in neonates]

Neonates are susceptible to respiratory viral infections, with outbreaks reported in areas with a high population of neonates, such as postpartum care centers and neonatal wards. While specific antiviral drugs are currently available for influenza, symptomatic supportive treatment remains the primary approach for respiratory syncytial virus (RSV), making prevention particularly important. The article closely follows the "Expert recommendations for the prevention of common respiratory viral infections in neonates" and provides an in-depth interpretation of recent breakthroughs in RSV prevention. It discusses the physiological and immunological characteristics of neonates, the disease burden and transmission routes of RSV infection, the main clinical manifestations and long-term effects of RSV infection in neonates, as well as specific preventive measures against RSV and practical recommendations and prevention experiences for RSV from abroad to lay a foundation for RSV prevention and control in neonates in China.

Design and Development of an Integrated Virtual Reality (VR)-Based Training System for Difficult Airway Management

For over 40 years, airway management simulation has been a cornerstone of medical training, aiming to reduce procedural risks for critically ill patients. However, existing simulation technologies often lack the versatility and realism needed to replicate the cognitive and physical challenges of complex airway management scenarios. We developed a novel Virtual Reality (VR)-based simulation system designed to enhance immersive airway management training and research. This system integrates physical and virtual environments with an external sensory framework to capture high-fidelity data on user performance. Advanced calibration techniques ensure precise positional tracking and realistic physics-based interactions, providing a cohesive mixed-reality experience. Validation studies conducted in a dedicated medical training center demonstrated the system's effectiveness in replicating real-world conditions. Positional calibration accuracy was achieved within 0.1 cm, with parameter calibrations showing no significant discrepancies. Validation using Pre- and post-simulation surveys indicated positive feedback on training aspects, perceived usefulness, and ease of use. These results suggest that the system offers a significant improvement in procedural and cognitive training for high-stakes medical environments.

VV-ECMO adjuvant therapy for Leptospira complicated with H1N1 infection: a case report

Background

Leptospirosis is an acute infectious disease that occurs by infection, progresses rapidly, and has a high mortality rate, with an estimated 1.2 million new cases and nearly 59,000 deaths each year. Due to its diverse clinical manifestations, diagnosis is often delayed. Therefore, it is necessary to pay attention to its clinical manifestations, diagnostic techniques, and treatment methods.

Case report

A 51-year-old male patient from the Han ethnic group experienced fever, chills, headache, and overall fatigue after being exposed to rain, followed by yellowing of the skin and worsening of breathing difficulties. Metagenomic next-generation sequencing (mNGS) indicates infection with leptospirosis and influenza A. After 5 days of treatment with venovenous extracorporeal membrane oxygenation (VV-ECMO), Penicillium, and Oseltamivir, the condition improved.

Conclusion

Leptospirosis improves with VV-ECMO support and anti-infective treatment with penicillin and oseltamivir. VV-ECMO provides a therapeutic time window for rescue, and mNGS lays a foundation for early detection of etiology of leptospirosis.

Scrub Typhus and Influenza A Co-Infection: A Case Report

Scrub typhus, caused by Orientia tsutsugamushi, is a neglected and reemerging disease that causes considerable morbidity and mortality. It now extends beyond the Tsutsugamushi Triangle, the region wherein it has traditionally been endemic. Influenza has also resurged since the infection control measures against COVID-19 were relaxed. A few cases of scrub typhus and influenza co-infection have been reported. Herein, we report the case of a 74-year-old woman with fever and upper respiratory symptoms diagnosed with influenza A and treated with oseltamivir; however, her fever persisted, and she developed respiratory failure, liver dysfunction, headache, diarrhea, and an erythematous skin rash. She lived in a forested area where scrub typhus was endemic and worked on a farm. Physical examination revealed an eschar on her posterior neck, and she was diagnosed with scrub typhus and influenza A co-infection. After minocycline treatment, her symptoms improved within a few days. This is the first reported case of scrub typhus and influenza A co-infection in Japan. This case illustrates that co-infection should be suspected in patients with fever persisting after their initial infection has been treated and that in patients living in endemic areas, scrub typhus can occur concurrently with influenza. The symptoms of scrub typhus are flu-like and nonspecific, which may delay diagnosis and treatment.

Ventilator-Associated Pneumonia in Low- and Middle-Income vs High-Income Countries: The Role of Ventilator Bundle, Ventilation Practices, and Health Care Staffing

BACKGROUND

Ventilator-associated pneumonia (VAP) rates are higher in low- and middle-income countries (LMICs) than in high-income countries (HICs).

RESEARCH QUESTION

Could differences in ventilator bundle adherence, ventilation practices, and critical care staffing be driving variations in VAP risk between LMICs and HICs?

STUDY DESIGN AND METHODS

This secondary analysis of the multicenter, international Checklist for Early Recognition and Treatment of Acute Illness and Injury (CERTAIN) study included mechanically ventilated patients at risk for VAP from 11 LMICs and 5 HICs. We included oral care, head-of-bed elevation, spontaneous breathing assessments, and sedation breaks in the ventilator bundle. Staffing was assessed by the number of physicians and nurses per bed. Multivariable analyses were adjusted for severity, baseline characteristics, and checklist implementation. The primary outcome was VAP development.

RESULTS

Among 2,253 patients, 1,755 were from LMICs and 498 from HICs. Compared with HICs, patients from LMICs were younger, had lower comorbidity burden, and were less severely ill. Lower country income level was independently associated with VAP development (adjusted OR [aOR], 2.11; 95% CI, 1.37-3.24). Ventilator bundle adherence was not significantly associated with VAP. Increased total duration of ventilation was associated with an increased risk of VAP (aOR, 1.04; 95% CI, 1.03-1.05), whereas higher nursing (aOR, 0.88; 95% CI, 0.79-0.98) and physician staffing ratios (aOR, 0.69; 95% CI, 0.50-0.87) were associated with lower VAP rates.

INTERPRETATION

Our results show that patients in LMICs have a 2-fold higher risk of VAP, independent of bundle adherence. Prolonged mechanical ventilation was an independent predictor of VAP, whereas higher staffing ratios were associated with decreased risk for VAP development. Unmeasured factors (eg, infrastructure, infection control practices) may explain the higher VAP rates in LMICs.

The endothelium or mitochondrial level therapy: new frontiers in sepsis?

The host and microbes play complex roles in balancing the pro- and anti-inflammatory pathways that cause sepsis. It is now increasingly recognized as a disorder of the mitochondrial system intrinsically or as a consequence of microcirculatory abnormalities leading to hypoperfusion/hypoxia ("microcirculatory and mitochondrial distress syndrome"). It is expected that improvements in endothelium or mitochondrial level therapy will lower sepsis-related morbidity and mortality. This article aimed to clarify the mitochondrial and microcirculation abnormalities in patients with sepsis and the futuristic research agenda for the management of sepsis.

Diagnostic Utility of Procalcitonin and Lactate Determination in Cerebrospinal Fluid for the Diagnosis of Neonatal Meningitis

Objectives: The diagnosis of meningitis is based on microbiological analysis of the cerebrospinal fluid, and the evaluation of cytosis and biochemical parameters such as protein and glucose levels. Sometimes when there is a traumatic lumber puncture, the cerebrospinal fluid is bloody, which makes it difficult to diagnose. The objective of the study was to examine the performance of cerebrospinal fluid (CSF) procalcitonin (PCT) and lactate as potential markers for the diagnosis of meningitis in neonates. Methods: 110 neonates who qualified for lumbar puncture were enrolled in the study. On the basis of CSF analysis, the neonates were classified into two groups: the meningitis group (n = 33) and the non-meningitis group (n = 77). PCT and lactate in CSF and established CSF parameters were recorded. Results: Median CSF PCT level was significantly higher in the meningitis group compared to non-meningitis: 0.93 (0.39-1.59) vs. 0.34 (0.195-0.74) ng/mL, p < 0.000001. Median CSF lactate level was significantly higher in the meningitis group compared to non-meningitis: 3.1 (2.27-3.96) vs. 1.78 (1.38-3.19) mmol/L, p < 0.001. At a cutoff of 0.35 ng/mL, CSF PCT had a sensitivity of 82% and specificity of 52% in the diagnosis of meningitis (AUC = 0.7). At a cutoff of 2.07 mmol/L, CSF lactate had a sensitivity of 84% and specificity of 60% in the diagnosis of meningitis (AUC = 0.701). Conclusions: Concentrations in CSF of PCT and lactate in neonates with meningitis are significantly higher than in the non-meningitis group. None of the biochemical indicators studied met the criteria for a marker for the diagnosis of meningitis as a single indicator.

Unseen Enemy: Mechanisms of Multidrug Antimicrobial Resistance in Gram-Negative ESKAPE Pathogens

Multidrug antimicrobial resistance (AMR) represents a formidable challenge in the therapy of infectious diseases, triggered by the particularly concerning gram-negative Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp. (ESKAPE) pathogens. Designated as a "priority" in 2017, these bacteria continue to pose a significant threat in 2024, particularly during the worldwide SARS-CoV-2 pandemic, where coinfections with ESKAPE members contributed to worsened patient outcomes. The declining effectiveness of current treatments against these pathogens has led to an increased disease burden and an increase in mortality rates globally. This review explores the sophisticated mechanisms driving AMR in gram-negative ESKAPE bacteria, focusing on Acinetobacter baumannii, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Enterobacter spp. Key bacterial mechanisms contributing to resistance include limitations in drug uptake, production of antibiotic-degrading enzymes, alterations in drug target sites, and enhanced drug efflux systems. Comprehending these pathways is vital for formulating innovative therapeutic strategies and tackling the ongoing threat posed by these resistant pathogens.

Drp1-associated genes implicated in sepsis survival

Sepsis is a severe and life-threatening medical syndrome that can lead to organ failure and death. Despite advances in medical treatment, current therapies are often inadequate, with high septic mortality rates. Therefore, there is a critical need for reliable prognostic markers to be used in clinical settings to improve the management and outcomes of patients with sepsis. Recent studies have suggested that mitochondrial dynamics, including the processes of mitochondrial fission and fusion, are closely related to the severity of sepsis and the status of inflammation. By monitoring transcriptomic signals related to mitochondrial dynamics, new and reliable biomarkers can be engineered to more accurately predict sepsis survival risk. Such biomarkers would be invaluable in clinical settings, aiding healthcare providers in the early identification of high-risk patients and improving treatment strategies. To achieve this goal, we utilized the major mitochondrial fission regulatory protein dynamin-related protein 1 (Drp1, gene code DNM1L) and identified Drp1-associated genes that are enriched with sepsis survival genes. A 12-gene signature (GS) was established as a differentially expressed gene (DEG)-based GS. Next, we compared genes of proteins that interact with Drp1 to sepsis survival genes and identified 7 common genes, establishing a GS we term as protein-protein interaction (PPI)-based GS. To evaluate if these GSs can predict sepsis survival, we used publicly available human blood transcriptomic datasets from sepsis patients. We confirmed that both GSs can successfully predict sepsis survival in both discovery and validation cohorts with high sensitivity and specificity, with the PPI-based GS showing enhanced prognostic performance. Together, this study successfully engineers a new and validated blood-borne biomarker (PPI-based 7-gene GS) for sepsis survival risk prediction. This biomarker holds the potential for improving the early identification of high-risk sepsis patients and optimizing personalized treatment strategies to reduce sepsis mortality.

Acute embolic infarcts of bilateral cerebellar lobes, cerebral peduncles, thalami and left parietal lobe cortex following HIPEC surgery

Cytoreductive surgery and intraoperative, intraperitoneal hyperthermic chemoperfusion (hyperthermic intraperitoneal intraoperative chemotherapy) are commonly used for the management of peritoneal surface metastases. We describe a case of acute embolic infarcts in bilateral cerebellar lobes, cerebral peduncles, thalamus and left parietal lobe cortex in a postmenopausal woman in her 50s diagnosed with bilateral ovarian mucinous adenocarcinoma with peritoneal metastasis under general anaesthesia.

A conformational change of C-reactive protein drives neutrophil extracellular trap formation in inflammation

BACKGROUND

C-reactive protein (CRP) represents a routine diagnostic marker of inflammation. Dissociation of native pentameric CRP (pCRP) into the monomeric structure (mCRP) liberates proinflammatory features, presumably contributing to excessive immune cell activation via unknown molecular mechanisms.

RESULTS

In a multi-translational study of systemic inflammation, we found a time- and inflammation-dependent pCRP dissociation into mCRP. We were able to confirm that mCRP co-localizes with leukocytes at the site of injury after polytrauma and therefore assessed whether the CRP conformation potentiates neutrophil activation. We found mCRP-induced neutrophil-extracellular trap formation in vitro and ex vivo involving nicotinamide adenine dinucleotide phosphate oxidase activation, p38/mitogen-activated protein kinase signaling, and histone H3 citrullination. Mimicking the trauma milieu in a human ex vivo whole blood model, we found significant mCRP generation as well as NET formation, prevented by blocking pCRP conformational changes.

CONCLUSIONS

Our data provide novel molecular insights how CRP dissociation contributes to neutrophil activation as driver of various inflammatory disorders.

Characterization of children's prospective prescription review and exploration of factors influencing the success of interventions

Background

Medication safety is crucial in clinical care. Although many hospitals have implemented prospective prescription review systems to manage medication use, the impact of these systems on pediatric patients is not yet fully understood.

Objectives

We explore the characteristics and economic impacts of pediatric prospective prescription review and identify factors influencing intervention success rates.

Design

This study adopted a cross-sectional design.

Methods

Prospective prescription review tasks were compared in the outpatient of our hospital between 2021 and 2023 to assess medication rationalization rates and cost variability. Data were collected using the PASS PharmReview system, including patient information, medication indications, prescribing physicians, intervention pharmacists, prescription rationality rate, and medication costs. SPSS 26.0 software was used to compare changes in medication rationality and medication costs between the initial (2021) and stable (2023) periods and to analyze factors affecting intervention success during the stable period by the logistic regression model.

Results

The study included 11,533,807 prospective prescription review tasks. The medication rationalization rate increased from 92.0% to 95.7% (p < 0.05) between the initial (n = 5,392,551) and stabilization periods (n = 6,141,256). Outpatient medication costs per capita decreased by 3.2%, from ¥320.7 to ¥310.5. Factors influencing intervention success included the following: the greater age is negatively associated with success(p < 0.001, odds ratio (OR) = 0.98); internal medicine demonstrates a superior intervention success rate compared to the surgical department (p < 0.001, OR = 1.37); higher physician titles were associated with lower success rates (p < 0.001, OR = 0.59); and success increased with pharmacists of higher educational levels (p < 0.001, OR = 1.18).

Conclusion

Implementing a prospective prescription review system in pediatric outpatient settings improves medication rationality and reduces errors and costs, with intervention success influenced by patient age, department, physician titles, and the educational level of pharmacists.

Extracorporeal membrane oxygenation for Chinese neonates with severe respiratory and cardiac failure

OBJECTIVE

We aimed to outline the experience with extracorporeal membrane oxygenation (ECMO) for respiratory and cardiac failure in neonates in our institution and compare our results with those from other countries.

METHOD

The clinical data of 28 neonates who required ECMO assistance were studied retrospectively.

RESULTS

A total of 28 neonates underwent support with veno-arterial ECMO, including 14 cardiac support and 14 respiratory support. The neonates with a median age of 5 days (1-28 days) and a median weight of 3.3 kg (2.4-4.2 kg). Of these neonates, 4 were female, and 24 were male. Among the neonates. For neonates requiring ECMO support for cardiac conditions, 9 survived, resulting in a 64% survival rate. In contrast, for those requiring ECMO support for respiratory conditions, 6 survived, indicating a 42% survival rate. The survivors exhibited a significant reduction in lactic acid levels within the first 24 h. In the 15 successful weaning neonates, four neonates died at the end of the study; one was for the cardiac function failure; two were for the respiratory failure; one was given up for Bipedal necrosis; the other 11 neonates were successful discharge. Notably, two neonates underwent ECMO ventilation in the prone position without experiencing any complications.

CONCLUSION

The utilization of ECMO support in neonates experiencing severe respiratory and cardiac failure efficiently improves cardiopulmonary function and significantly reduces mortality rates among critically ill neonates. The neonates with a respiratory indication in our study have a lower survival rate than other reported in the literature. Monitoring the trend in lactate levels following ECMO support proves valuable in estimating the prognosis of affected children.

Immune Cell-Based versus Albumin-Based Ratios as Outcome Predictors in Critically Ill COVID-19 Patients

Purpose

The aim of the retrospective, single-center study was to assess the prognostic value of immune cell-based and albumin-based ratios regarding lethal outcome in critically ill COVID-19 patients.

Patients and Methods

We analyzed 612 adult critically ill COVID-19 patients admitted to the intensive care unit (ICU) between April 2020 and November 2022. Blood measurement on admission to the ICU encompassed complete blood count (CBC), IL-6, C-reactive protein (CRP), albumin, lactate, lactate dehydrogenase (LDH), serum bicarbonate, arterial base deficit/excess (BD/E), and D-dimer. All the measured and calculated parameters were compared between survivors and nonsurvivors, with the outcome measure being hospital mortality.

Results

Immune cell-based ratios [NLR - Neutrophil-to-Lymphocyte Ratio, MLR - Monocyte-to-Lymphocyte Ratio, PLR - Platelet-to-Lymphocyte Ratio, MPV - Mean Platelet Volume, MPV/PC - Mean Platelet Volume-to-Platelet Count Ratio, Derived (d-)NLR ratio - neutrophil count divided by the result of white blood cell (WBC) count - neutrophil count), N/LP - Neutrophil count x 100/Lymphocyte count x Platelet count, CLR - C-reactive protein (CRP)-to-Lymphocyte Ratio, CPR - CRP-to-Platelet Ratio, LLR - Lactate dehydrogenase (LDH)-to-Lymphocyte Ratio, Systemic Immune Inflammation Index (SII) - platelet x neutrophil/lymphocyte count, Systemic Inflammation Response Index (SIRI) - neutrophil x monocyte/lymphocyte count] were investigated. White blood cell and neutrophil counts were significantly higher, while lymphocyte and platelet counts were significantly lower in nonsurvivors. MPV, MPV/PC, NLR, d-NLR, MLR, N/LP, CRP, LDH, CPR, CLR, LLR, SII, and SIRI values were significantly higher in nonsurvivors. Monocyte count and PLR values did not differ significantly between groups. Albumin-based ratios included CRP-to-Albumin Ratio (CAR), Lactate-to-Albumin Ratio (LAR) and LDH-to-Albumin Ratio (LDH/ALB). All values were significantly higher in nonsurvivors.

Conclusion

The only independent predictor of lethal outcomes at ICU admission is the albumin-based LDH/ALB ratio. Most of the other parameters were moderate, although highly significant predictors of mortality in critically ill COVID-19 patients.

Risk factors for bloodstream infection in COVID-19 patients in intensive care units: a systematic review and meta-analysis

BACKGROUND

Risk factors for bloodstream infection in patients with COVID-19 in the intensive care unit (ICU) remain unclear. The purpose of this systematic review was to study the risk factors for BSI in patients admitted to ICUs for COVID-19.

METHODS

A systematic search was performed on PubMed, EMBASE, Cochrane Library, and Web of Science up to July 2024. Data were reported as combined odds ratio (OR) for categorical variables and weighted mean difference (WMD) for continuous variables.

RESULTS

6914 studies were retrieved, of which 55 were included in the meta-analysis. Men (OR = 1.28, 95% CI: 1.10-1.50, P = 0.006), high SAPS II score (WMD = 6.43, 95% CI: 0.23-12.63, P = 0.042), diabetes (OR = 1.34, 95% CI: 1.04-1.73, P = 0.022), tracheal intubation (OR = 8.68, 95% CI: 4.68-16.08, P < 0.001), mechanical ventilation (OR = 22.00, 95% CI: 3.77-128.328, P < 0.001), ECMO (OR = 2.70, 95% CI: 1.17-6.26, P = 0.020), central venous cannulation (OR = 9.33, 95% CI: 3.06-28.43, P < 0.001), prolonged ICU stay (WMD = 10.37, 95% CI: 9.29-11.44, P < 0.001), methylprednisolone use (OR = 2.24, 95% CI: 1.24-4.04, P = 0.008), and the combination of methylprednisolone and Tocilizumab (OR = 4.54, 95% CI: 1.09-18.88, P = 0.037) were risk factors for ICU-BSI in COVID-19 patients.

CONCLUSION

We identified 10 risk factors for ICU-BSI in COVID-19 patients. In future studies, these factors can be combined to establish a more comprehensive and accurate prediction model for ICU-BSI in COVID-19 patients. Targeted measures can be taken earlier to control BSI.

Successful Management of Rapidly Progressive Interstitial Pneumonia With Autoimmune Features in an Elderly Patient: A Case Report

An 82-year-old man presented with acute respiratory distress, a one-week history of dry cough, and worsening dyspnea. Chest computed tomography revealed bilateral diffuse ground-glass opacities, raising suspicion of rapidly progressive interstitial pneumonia. Rapid autoantibody testing confirmed interstitial pneumonia with autoimmune features (IPAF), likely triggered by an upper respiratory infection. Initial treatment with high-dose steroid pulse therapy was insufficient to stabilize the patient's respiratory status. Cyclophosphamide pulse therapy was initiated on day 4, resulting in significant improvement by day 7. The patient's oxygen requirements steadily decreased, and follow-up imaging showed near-complete resolution of lung abnormalities. Intensive immunosuppressive therapy, infection control measures, and tailored supportive care enabled functional recovery and discharge to a rehabilitation facility. This case highlights the importance of early diagnosis, rapid immunological evaluation, and aggressive immunosuppressive therapy in managing rapidly progressive interstitial pneumonia in elderly patients. Individualized treatment plans based on overall health rather than biological age can significantly improve outcomes, even in critically ill elderly patients. Early initiation of multidisciplinary care is crucial to achieving remission and restoring quality of life in this challenging population.