Does enteral nutrition protect against stress ulceration in the critically ill?

PURPOSE OF REVIEW

Critically ill patients are at risk of gastrointestinal bleeding (GIB) due to stress ulceration. Strategies to reduce the risk include administration of prophylactic ulcer healing medications. Enteral nutrition (EN) may be favourably associated with GIB risks. This manuscript summarizes available evidence regarding EN effects on GIB.

RECENT FINDINGS

There are few data available to directly compare the effect of EN on GIB. Direct comparison in animal models generally indicate a beneficial effect. Human data provide indirect evidence from pharmacological stress ulcer prophylaxis studies. EN exposure has been randomized in nutrition trials of critically ill patients, but GIB outcomes were not recorded. Detailed EN exposure data were recorded in two large pharmacological stress ulcer trials. One finds EN is associated with lower GIB, lower mortality, and increased pneumonia, and notes a possible interaction between EN and pharmacological stress ulcer prophylaxis. The second has yet to report associations with EN.

SUMMARY

EN may reduce the risk of GIB, although robust direct evidence is absent. Potential interactions between EN and pharmacological stress ulcer prophylaxis require further study.

Promoting Resiliency to Stress in the Vascular Endothelium

By 2050, roughly 60% of the population will have cardiovascular disease. While a substantial amount of data has been generated over the last few decades that has aided in our understanding of cardiovascular disease pathology, less is known about how to increase resiliency to cardiovascular risk factors that individuals are exposed to on a daily basis. The vascular endothelium is considered the first line of defence against circulating noxious stimuli and, when dysfunctional, is an early risk factor for the development of cardiovascular disease. A vast amount of data has been generated demonstrating how external stress impairs the vascular endothelium; however, there is a paucity of knowledge regarding how to amplify protective pathways and ward off stress and the development of disease, which is the focus of this review. Targeting known protective endothelial pathways may be feasible to increase resiliency to vascular stress. Leveraging stress to boost defence mechanisms within the vascular endothelium is also proposed and may help identify novel therapeutic targets to protect individuals from the stress of everyday life.

Ten years of Basic Life Support provider course: results and challenges from the Italian Resuscitation Council's experience

Introduction

Widespread basic life support (BLS) training plays a central role in improving cardiac arrest (CA) survival. This study presents an extensive analysis of numbers, candidates' characteristics, and outcomes over 10 years of BLS provider courses organized by the Italian Resuscitation Council (IRC) in Italy.

Method

This is a retrospective analysis of data recorded in the national IRC BLS training database from January 2014 to December 2023. Candidates' demographic and professional factors were analyzed with regional differences and course outcomes.

Results

Over the study period, a total 906,686 candidates attended the course, 646,743 (71.3%) of whom were healthcare professionals (HP) and 259,943 (28.8%) non-healthcare professionals (NHP). The percentage of candidates passing the final exam was 99.5% for HP and 99.8% for NHP. The rate per 1000 HP per year of physicians and nurses attending the BLS course varied considerably across the Italian regions, ranging from 4.2 in central Italy to 669.7 in some northern areas. The rate per 1000 inhabitants of NHP per year attending the BLS course was also different among regions, varying from 0.1 in the southern and central regions up to 1.7 in the northern and northeastern ones.

Conclusion

The pass rate of the BLS provider course is overall very high, indicating that it provides an easy and accessible set of skills for both HP and NHP candidates. Regional disparities (e.g. the rates of trained individuals and distribution between HP and NHP) and the low attendance of retraining courses represent important challenges that need to be addressed. Analysing training registers is a valuable tool for better planning future training projects.

The Risk of Propofol Infusion Syndrome on Epilepsy Patients :Insights from FAERS Data and Published Case Reports

OBJECTIVE

PRIS has been documented in epilepsy patients treated with propofol. But the clinical features associated with the occurrence of PRIS in patients with epilepsy remain incompletely elucidated. This study aimed to investigate the relationship between epilepsy, antiepileptic drugs, and PRIS and draw conclusions about its clinical features.

METHODS

Extracted PRIS reports documented in the FAERS (January 2013 to December 2023). Epilepsy patients and non-epilepsy patients were distinguished based on the indication information. We performed multivariate analyses for demography, epilepsy status, and the use of antiepileptic drugs between these two populations. Additionally, we collected all published reports on propofol usage that resulted in PRIS. We focused on the differences in clinical manifestations of PRIS between epilepsy patients and non-epilepsy patients and analyzed them retrospectively.

RESULTS

For 349 PRIS cases in the FAERS database, 94 cases involved epilepsy. Epilepsy was a significant risk factor for PRIS development (ROR = 3.89) and death outcomes (ROR = 1.997). Further analysis of antiepileptic drug regimens revealed that valproic acid was associated with an increased risk of PRIS (ROR = 3.264) and adverse outcomes (ROR = 2.518). For 185 PRIS cases in this review, 49 demonstrated a history of epilepsy. Patients with epilepsy displayed a lower median infusion rate of propofol than those without but a higher median cumulative dose.

CONCLUSION

When using propofol, epilepsy patients are at high risk of PRIS and are vulnerable to death. Therefore, patients with epilepsy must be closely monitored for safety during treatment, especially when they using valproic acid.

Fluid excess on intensive care unit after mechanical thrombectomy after acute ischemic stroke is associated with unfavorable neurological and functional outcomes: An observational cohort study

INTRODUCTION

Endovascular thrombectomy stands as a pivotal component in the standard care for patients experiencing acute ischemic stroke with large vessel occlusion. Subsequent care for patients often extends to a neurological intensive care unit. While fluid management is integral to intensive care, the association between early fluid balance and neurological and functional outcomes post-thrombectomy has not yet been thoroughly investigated.

METHODS

In a retrospective analysis of an observational, single-center study spanning from 2015 to 2021 at the University Medical Center Hamburg-Eppendorf, Germany, we enrolled stroke patients who underwent thrombectomy and received subsequent treatment in the ICU. Unfavorable functional and neurological outcome was defined as a mRS > 2 on day 90 after admission (mRS d90) or NIHSS > 5 at discharge, respectively. A multivariate regression model, adjusting for confounders, utilized the average fluid balance in the first 5 days to predict outcomes. Patients were dichotomized by their average fluid balance (>1 L vs <1 L) within the first 5 days, and a multivariate mRS d90 shift analysis was conducted after adjusting for covariates.

RESULTS

Between 2015 and 2021, 1252 patients underwent thrombectomy, and 553 patients met the inclusion criteria (299 women [54%]). Unfavorable functional outcome was significantly associated with a higher daily average fluid balance in the first 5 days in the ICU (mRS d90 ⩽ 2: 0.3 ± 0.5 L, mRS d90 > 2: 0.7 ± 0.7 L, p = 0.02). The same association was observed for the NIHSS at discharge (NIHSS ⩽ 5: 0.3 ± 0.5 L; NIHSS > 5: 0.6 ± 0.6 L; p = 0.03). The mRS d90 shift analysis revealed significance for patients with an average fluid balance <1 L for better functional outcomes (adjusted odds ratio [AOR] 2.17; 95% confidence interval [CI] 1.54-3.07; p < 0.01).

DISCUSSION

Fluid retention in post-thrombectomy stroke patients in the ICU is associated with poorer functional and neurological outcomes. Consequently, fluid retention emerges as an additional potential predictor for post-intervention stroke outcomes. Our findings provide an initial indication that preventing excessive fluid retention in stroke patients after endovascular thrombectomy could be beneficial for both functional and neurological recovery. Therefore, fluid retention might be an element to consider in optimizing fluid management for stroke patients.

Multi-disciplinary investigation identifies increased potency of ethyl-parathion inhaled within a soil-dust matrix to cause acetylcholinesterase-dependent molecular impacts

Neurotoxicity investigations of inhaled organophosphorus pesticide (OP), ethyl-parathion (EP), were conducted in Sprague Dawley rats comparing exposures to EP volatilized at 0, 1, 10, and 20 mg/m3 versus EP incorporated into soil dust (5 mg/m3) at 0, 0.0095, 0.09, and 0.185 mg/mg3. All exposures were sublethal, caused no respiratory effects, and no effects on balance and coordination behavior. Both volatilized and dust-incorporated EP exposures significantly decreased acetylcholinesterase (AChE) activity in plasma and hippocampus tissue. Correspondingly, plasma and hippocampal dopamine levels spiked in these exposures suggesting compensatory cholinergic / dopaminergic signal balancing. The EP exposures significantly increased expression of pro-inflammatory genes, including MAPK-14, IL6, IL1β, and TNF-α, while global RNA-seq results identified significant enrichment of inflammation, oxidative stress, and apoptosis pathways. Remarkably, dust-incorporated EP impacted similar molecular endpoints as volatilized EP but at concentrations two orders of magnitude lower highlighting potentially increased potency of EP incorporated into soil dust.

Reduction of postoperative ileus in gastrointestinal surgery: systematic review and meta-analysis

BACKGROUND

Postoperative ileus is a surgical complication that affects intestinal motility. There are measures to reduce this problem, but not all have conclusive evidence. This study aimed to determine which measures, such as coffee, chewing gum (CG), electroacupuncture (EA), daikenchuto (DKT), and prokinetic agents, are most effective in reducing postoperative ileus in patients undergoing gastrointestinal surgeries.

METHODS

A systematic search was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines on Google Scholar, PubMed, ScienceDirect, and Web of Science. The following measures were studied to define postoperative ileus: time to passage of the first flatus and time to passage of the first stool. The mean differences were determined by subgroup analyses.

RESULTS

Of 176 studies, 37 were selected for the systematic review, which involved 4647 patients. The reduction in time to passage of the first flatus was -18.33 h (95% CI, -26.46 to -10.20; P <.01) for EA, -5.83 h (95% CI, -9.40 to -2.26; P <.01) for DKT, -14.87 h (95% CI, -26.84 to -2.90; P =.01) for CG, and -1.90 h (95% CI, -8.28 to 4.48; P =.56) for coffee. The reduction in time to passage of the first stool was -32.27 h (95% CI, -39.28 to -25.26; P <.01) for prokinetic agents, -23.05 h (95% CI, -29.31 to -16.78; P <.01) for CG, -12.89 h (95% CI, -17.78 to -8.01; P <.01) for coffee, -19.76 h (95% CI, -32.79 to -6.72; P <.01) for EA, and -0.70 h (95% CI, -25.51 to 26.92; P =.96) for DKT.

CONCLUSION

The use of CG, EA, and prokinetic agents decreased the time to passage of the first flatus and time to passage of the first stool and indirectly reduced postoperative ileus.

A systematic review on suction-based airway clearance devices for foreign body airway obstruction

OBJECTIVE

The objective of this systematic review is to comprehensively evaluate the effectiveness and safety of negative pressure, anti-choking devices (ACDs) in managing severe foreign body airway obstructions (FBAO) compared to traditional techniques such as the Heimlich maneuver.

METHODS

A comprehensive literature search was conducted in major databases to identify studies published within the past five years. Eligible studies were appraised for quality using the Critical Appraisal and Data Extraction Tool. Data on study design, outcomes, and safety parameters were extracted and analyzed.

RESULTS

The review identified studies evaluating various ACDs, including LifeVac and DeChoker, in different settings and populations. Results from retrospective studies and trials on mannequins or cadavers suggested promising outcomes for ACDs in relieving FBAO, with success rates ranging from 71% to 99%. However, concerns regarding usability, training, and adverse events were raised, emphasizing the need for further research.

CONCLUSIONS

Review emphasizes traditional maneuvers (thrusts/blows) for all rescuers. ACDs show promise, but further research is needed to determine their role alongside established methods. LifeVac's design may offer advantages in terms of ease of use, potentially requiring less dexterity compared to Dechoker. Regardless of the device, proper training remains crucial for optimal effectiveness and safe use. Combining ACDs with traditional methods like abdominal thrusts and back blows may be a promising approach for improving airway obstruction management.

National screening for delirium in paediatric intensive care units: A quality improvement initiative

BACKGROUND

Internationally, one in three children develop delirium during their intensive care stay. International guidelines strongly recommend twice-daily screening for paediatric delirium using validated instruments. In the United Kingdom and Ireland, delirium was assessed only when suspected and few intensive care units (ICUs) used validated instruments.

AIM

This initiative aimed to implement a national screening strategy in 28 paediatric intensive care units (PICUs) across the United Kingdom and Ireland.

STUDY DESIGN

The strategy involved: (a) rapidly reviewing, evaluating and ranking paediatric screening instruments for sensitivity, specificity, appropriateness and acceptability for national implementation; (b) achieving national agreement to implement a common tool; (c) creating and disseminating training materials while supporting training personnel in implementation; and (d) integrating delirium monitoring within the Paediatric Intensive Care Audit Network national database.

RESULTS

Among seven validated instruments, the top ranked options (from 1, most applicable to 7, least applicable) were the Cornell Assessment of Pediatric Delirium (average rank 1.25) and the Sophia Observation withdrawal Symptoms-Paediatric Delirium scale (1.5). Twenty-three units voted for their preferred choice of instrument: fifteen preferred the Cornell instrument, eight favoured the Sophia instrument and five did not respond. Training and implementation began in November 2021 and by March 2023 18 of the 28 units (64%) had successfully implemented screening. The national database began actively collecting delirium data from units in January 2024.

CONCLUSIONS

This initiative outlined critical steps for implementing and maintaining practice of delirium screening in PICUs. We provided clinicians with validated screening tools for detecting paediatric delirium and the necessary support and infrastructure to maintain screening. Embedding and sustaining screening is an ongoing challenge.

RELEVANCE TO CLINICAL PRACTICE

Undertaking routine screening for all intensive care patients from admission to discharge using validated instruments will provide earlier detection and treatment for critically ill children. This strategy offers a model for standardized and effective implementation in clinical practice in ICUs.

Pharmacological Management of Sleep-Wake Disturbances in Delirium

Delirium is a heterogeneous syndrome primarily characterized by fluctuations in attention and awareness. Sleep-wake disturbances are a common and significant feature of delirium and can manifest as circadian rhythm inversion, sleep fragmentation, and reduced rapid eye movement (REM) and slow-wave sleep. Some literature suggests that the relationship between sleep disruption and delirium is reciprocal wherein the two reinforce one another and may share an underlying etiology. As there are no FDA-approved medications for delirium or delirium-related sleep disturbances, management is primarily focused on addressing underlying medical concerns and promoting physiologic circadian patterns with non-pharmacological behavioral interventions. In practice, however, medications are often used, albeit with limited evidence to support their use. This literature review explores the pharmacology and pharmacokinetics of several medications with literature investigating their use in delirium: melatonin, ramelteon, dual orexin receptor antagonists (DORAs), and dexmedetomidine. Current evidence suggests a possible benefit of ramelteon or melatonin, dexmedetomidine for patients in the ICU setting, and DORAs as therapeutic options for the re-regulation of sleep-wake cycle disruption in delirium. We discuss pertinent pharmacokinetic and pharmacodynamic factors that may influence clinical decision-making regarding these interventions.

Regional anesthesia modalities in blunt thoracic trauma: A systematic review and Bayesian network meta-analysis

BACKGROUND

Various regional anesthesia techniques have been studied for blunt chest wall trauma over the past decades, but their impact on patient outcomes remains unclear. This systematic review and Bayesian network meta-analysis aimed to identify the most effective regional anesthesia techniques for different outcomes in blunt thoracic trauma patients.

METHODS

We searched Medline, EMBASE, Scopus, and Cochrane databases for randomized controlled trials comparing regional anesthesia techniques (thoracic epidural, erector spinae plane block, serratus anterior plane block, intercostal block, paravertebral block, intrapleural block, retrolaminar block) and standard intravenous analgesia. Eligible studies reported at least one of the following outcomes: pain control, ICU and hospital length of stay, mechanical ventilation duration, pneumonia incidence, and additional analgesic use. Bayesian network meta-analysis models were created for each outcome, and confidence in results was assessed using the CINeMA framework.

RESULTS

We included 27 randomized controlled trials with 1586 patients. Thoracic epidural consistently showed efficacy in reducing pain at 24 h, mechanical ventilation duration, and ICU and hospital stays. The erector spinae plane block also reduced pain and hospital stay. Confidence in these results was low to moderate, primarily due to imprecision.

CONCLUSIONS

Various locoregional techniques are being investigated for managing pain in blunt thoracic trauma, with thoracic epidural showing consistent positive effects on pain and other key outcomes. Fascial blocks are emerging as potential alternatives with similar pain relief, though evidence on other outcomes is limited. Future studies should compare the efficacy of these techniques on more definitive endpoints.

Hand vs. leg-heel: Evaluating a viable second line approach for chest compressions to bridge the 'bystander's window'

Introduction

High quality bystander cardiopulmonary resuscitation (CPR) substantially improves outcomes from cardiac arrest. However, chest compression (CC) quality may be impaired in situations of physical incapacitation, low body weight or rescuer fatigue. For such situations, the leg-heel'-approach has been proposed as an alternative. No study, however, has yet explored this method in a standardized setting over a realistic time span, e.g., until professional rescue teams arrive.

Methods

In a cross-over design, final year medical students performed continuous CC on a manikin using conventional (C-CPR) and 'leg-heel'-CPR (LH-CPR) for five minutes each with no pause between methods. Students were randomly assigned to the order of approaches. For the LH-CPR, a chair was provided for the rescuer to stabilize the upper body.

Results

121 students were included, and all participants completed the whole ten-minute-task.Mean absolute CC depth (C-CPR: 49.8 mm [SD 8.7, CI 48.2-51.4] vs. LH-CPR: 49.9 mm [SD 9.4, CI 48.2-51.5], p = 0.974) and mean leaning depth (C-CPR: 10.9 mm [SD 7.4, CI 9.6-12.3] vs. LH-CPR: 10.9 [SD 7.6, CI 9.6-12.3]), were similar, while mean CC frequency was higher in C-CPR (120/min [SD 13, CI 118-123] vs. 113/min [SD 16, 110-116], p < 0.01). With C-CPR, CC rate steadily increased over time up to 125/min whereas with LH-CPR it remained within the guideline target of 100-120/min. Over time, rescuer fatigue was slightly less pronounced in LH-CPR.

Discussion

In a standardized setting over a realistic time span, the 'leg-heel'-approach led to equal CPR quality as the conventional approach. Application of the 'leg-heel'-approach however, has to be considered with caution as its effects on haemodynamics and resuscitation-related injuries are unknown. Cases should therefore be carefully observed.

Summary

This finding may justify developing training algorithms for 'leg-heel'-CPR as a second line alternative in situations of fatigue, low body weight or physical incapacitation.

Digital Health Interventions Supporting Recovery for Intensive Care Patients and Their Family Members: A Scoping Review

Digital innovation in interventions to promote recovery for intensive care unit (ICU) patients and their family members holds promise for enhancing accessibility and improving physical, psychological, and cognitive outcomes. This scoping review provides a comprehensive overview of digital health interventions designed to support the recovery of ICU patients and their family members described in peer-reviewed publications. We searched 6 databases (inception to September 2023); 2 reviewers independently screened citations against predefined eligibility criteria and extracted data. We screened 3485 records and identified 18 original studies and 8 study protocols with a range of study designs published between 2016 and 2023. Most (n=15) completed studies recruited patients only. Digital interventions were delivered through applications, virtual reality, videoconferencing, and smartwatches. In the completed studies, outcomes are described as feasibility, intervention efficacy, or both. Digital interventions supplemented with professional support and personalized feedback were more feasible than self-directed interventions. Further research is essential to ascertain the efficacy and cost-effectiveness of digital interventions in improving outcomes for ICU survivors and their family members.

Predicting Inpatient Admissions From Emergency Department Triage Using Machine Learning: A Systematic Review

This study aimed to evaluate the quality of evidence for using machine learning models to predict inpatient admissions from emergency department triage data, ultimately aiming to improve patient flow management. A comprehensive literature search was conducted according to the PRISMA guidelines across 5 databases, PubMed, Embase, Web of Science, Scopus, and CINAHL, on August 1, 2024, for English-language studies published between August 1, 2014, and August 1, 2024. This yielded 700 articles, of which 66 were screened in full, and 31 met the inclusion and exclusion criteria. Model quality was assessed using the PROBAST appraisal tool and a modified TRIPOD+AI framework, alongside reported model performance metrics. Seven studies demonstrated rigorous methodology and promising in silico performance, with an area under the receiver operating characteristic ranging from 0.81 to 0.93. However, further performance analysis was limited by heterogeneity in model development and an unclear-to-high risk of bias and applicability concerns in the remaining 24 articles, as evaluated by the PROBAST tool. The current literature demonstrates a good degree of in silico accuracy in predicting inpatient admission from triage data alone. Future research should emphasize transparent model development and reporting, temporal validation, concept drift analysis, exploration of emerging artificial intelligence techniques, and analysis of real-world patient flow metrics to comprehensively assess the usefulness of these models.

Spinal Phlegmon Secondary to Neisseria meningitidis Meningitis With Possible Herpes Simplex Virus 1 Co-infection in an Immunocompetent Pediatric Patient

Spinal phlegmon has rarely been reported in meningococcemia. Simultaneous polymicrobial infection has been occasionally reported as the etiology of meningitis. The development of a spinal phlegmon and optic neuritis complicated meningitis in a five-year-old male who presented with clinical sepsis and meningitis. Neisseria meningitidis (N. meningitidis) and herpes simplex virus 1 (HSV-1) were demonstrated in the cerebrospinal fluid. Investigation of potential immunocompromise revealed no identified deficit. Protracted antibiotics and antiviral therapy were completed with a favorable clinical outcome. This is potentially the first reported case of spinal phlegmon associated with meningococcal meningitis in an immunocompetent pediatric patient. It occurred in the clinical context of what appeared to be a simultaneous infection by N. meningitidis and HSV-1.

The role of artificial intelligence in sepsis in the Emergency Department: a narrative review

Background and Objective

Early recognition and treatment of sepsis in the emergency department (ED) is important. Traditional predictive analytics and clinical decision rules lack accuracy in identifying patients with sepsis. Artificial intelligence (AI) is increasingly prevalent in healthcare and offers application potential in the care of patients with sepsis. This review examines the evidence of AI in diagnosing, managing and prognosticating sepsis in the ED.

Methods

We performed literature search in PubMed, Embase, Google Scholar and Scopus databases for studies published between 1 January 2010 and 30 June 2024 that evaluated the use of AI in adult patients with sepsis in ED, using the following search terms: ("artificial intelligence" OR "machine learning" OR "neural networks, computer" OR "deep learning" OR "natural language processing"), AND ("sepsis" OR "septic shock", AND "emergency services" OR "emergency department"). Independent searches were conducted in duplicate with discrepancies adjudicated by a third member.

Key Content and Findings

Incorporating multiple variables such as vital signs, free text input, laboratory tests and electrocardiogram was possible with AI compared to traditional models leading to improvement in diagnostic performance. Machine learning (ML) models outperformed traditional scoring tools in both diagnosis and prognosis of sepsis. ML models were able to analyze trends over time and showed utility in predicting mortality, severe sepsis and septic shock. Additionally, real-time ML-assisted alert systems are effective in improving time-to-antibiotic administration and ML algorithms can differentiate sepsis patients into distinct phenotypes to tailor management (especially fluid therapy and critical care interventions), potentially improving outcomes. Existing AI tools for sepsis currently lack generalizability and user acceptance. This is risk of automation bias with loss of clinicians' skills if over-reliance develops.

Conclusions

Overall, AI holds great promise in revolutionizing management of patients with sepsis in the ED as a clinical support tool. However, its application is currently still constrained by inherent limitations. Balanced integration of AI technology with clinician input is essential to harness its full potential and ensure optimal patient outcomes.

Multimodal anesthesia for hemicorporectomy suggests creating a standardized anesthesia guideline: a case report

Background

First performed in 1960, hemicorporectomy, or translumbar amputation, is a rare surgery performed as a last resort for patients with life-threatening diagnoses. While rare, it is associated with significant challenging events for the anesthesiologist. Here we present a challenging hemicorporectomy case which was successfully managed using a multimodal anesthesia approach.

Case Description

The patient was a 40-year-old patient presenting for completion of a hemicorporectomy via a left hemipelvectomy for pelvic chondrosarcoma. The patient underwent hemicorporectomy under epidural and total intravenous anesthesia supplemented with ketamine and lidocaine infusion. The surgery lasted 17.5 h and resulted in 28 L of blood loss. The patient noted excellent pain control and was discharged on postoperative day 74 following an uncomplicated hospital course and in-house rehabilitation.

Conclusions

Reviewing the literature, we recognized that there are no standardized anesthesia protocols published for hemicorporectomy. Based on our case report we present a novel anesthesia strategy that addresses almost all major challenges with hemicorporectomies. Our successful strategy suggests that a total intravenous anesthesia with propofol in combination with an epidural and a multimodal pain regimen with rate adjustments based on body mass reduction should be considered as a standard anesthesia protocol for hemicorporectomies. We recommend establishing a state-of-the-art anesthesia guideline for patients undergoing hemicorporectomy and encourage anesthesiologists to publish case reports describing the anesthesia approach for a hemicorporectomy.

Surgical strategy for chest wall reconstruction secondary to cardiopulmonary resuscitation versus post-traumatic

PURPOSE

In mechanically cardiopulmonary resuscitated (CPR) patients, chest compressions at the level of the 3rd to 5th rib on the sternum result in reproducibly similar injury patterns: parasternal osteochondral dissociation (OCS) on both sides in combination with a sternal fracture with or without an additional serial rib fracture in the anterolateral column (ALS). This injury biomechanically impairs physiological breathing, resulting in an inverse breathing pattern. Trauma patients, on the other hand, often show a mixed pattern depending on the location of the main energy. The aim of the study was to evaluate the surgical technique of chest wall reconstruction (CWR) using transsternal refixation of the 5th rib on both sides in combination with plate osteosynthesis of the sternum and to analyze its success in comparison to the surgical strategy of CWR in the context of a traumatic genesis.

METHOD

Data acquisition was performed using medical records of a Level I Trauma Centre in Germany and compare patients with radiologically or clinically diagnosed flail chest as a result of cardiopulmonary mechanical resuscitation (CPR). The retrospective study included patients in the period 2018-2023 after surgical CWR. The patients were either post-CPR (n = 29; CPR) or trauma patients (n = 36; trauma). The collective was described and analyzed using the digital patient file, as well as data on ICU stay and duration of ventilation or conversion to assisted ventilation modes, reason for chest wall instability, time of surgery, length of stay and mortality. As a long-term follow-up, body plethysmography was analyzed comparatively. Primary endpoints were mean length of stay in ICU, time to surgery, ventilator dependency and mortality rate. Secondary endpoints were time to transfer to rehabilitation, ventilation disorders and long term outcome.

RESULTS

In the period 65 patients (48 m, 17w) were included, 29 of whom had been mechanically resuscitated (CPR), 36 formed to post-traumatic cohort (trauma). The CPR were significantly older (69 vs. 58 years; p-value 0.003). The duration from CPR to surgery was on average significantly longer than trauma to surgery (16.76 vs. 4.11 days). The mean length of stay in ICU were 30 days (trauma) and 45 days for CPR (significantly longer, p-value 0.0008). The mean duration of ventilation was 188 h for trauma and 593 h for CPR. Extubation or conversion to assisted, relevant de-escalating ventilation modes was possible in both groups after a mean of 38 h post-OP. Among the CPR patients, 4 died in hospital (hospital mortality: CPR 20.7% vs. trauma 5.6%), 7 (30%) were transferred to an early clinical rehabilitation and 10 were discharged to home or follow-up treatment. In the case of trauma, 5 (14.7%) were transferred to an early clinical rehabilitation and 20 were discharged to home or follow-up treatment. Bodyplethysmography 6 months after CPR / trauma showed no differences in both collectives with regard to ventilation disorders. Diffusion was prolonged in both groups, presumably due to the healing process of lungs contusion. Both showed no restriction disorders.

CONCLUSION

Chest wall reconstruction, including plate osteosynthesis of the sternum in combination with transsternal fixation of the 5th rib on both sides can largely restore physiological respiratory mechanics immediately after surgery and accelerate the weaning success. In the management of patients after CPR, the initial diagnosis which had indicated resuscitation, is the main focus and can often be an obstacle to extubation. Nevertheless, independent breathing can be accelerated by restoring the biomechanics through early surgical treatment using CWR and saves long-term ICU stays with the potential for further complication and resource consumption. CWR forms the essential basis for early rehabilitation of the underlying cause of resuscitation. Ventilation disorders do not occur after surgical CWR, even during the course of the procedure.

A review of gut failure as a cause and consequence of critical illness

In critical illness, all elements of gut function are perturbed. Dysbiosis develops as the gut microbial community loses taxonomic diversity and new virulence factors appear. Intestinal permeability increases, allowing for translocation of bacteria and/or bacterial products. Epithelial function is altered at a cellular level and homeostasis of the epithelial monolayer is compromised by increased intestinal epithelial cell death and decreased proliferation. Gut immunity is impaired with simultaneous activation of maladaptive pro- and anti-inflammatory signals leading to both tissue damage and susceptibility to infections. Additionally, splanchnic vasoconstriction leads to decreased blood flow with local ischemic changes. Together, these interrelated elements of gastrointestinal dysfunction drive and then perpetuate multi-organ dysfunction syndrome. Despite the clear importance of maintaining gut homeostasis, there are very few reliable measures of gut function in critical illness. Further, while multiple therapeutic strategies have been proposed, most have not been shown to conclusively demonstrate benefit, and care is still largely supportive. The key role of the gut in critical illness was the subject of the tenth Perioperative Quality Initiative meeting, a conference to summarize the current state of the literature and identify key knowledge gaps for future study. This review is the product of that conference.

Flight testing of drone-delivered automated external defibrillators for simulated out-of-hospital cardiac arrest in suburban Thailand

The use of automated external defibrillators (AEDs) in a timely manner is critical for improving survival rates in out-of-hospital cardiac arrest (OHCA) cases. However, in developing countries, logistical and infrastructural challenges often result in delays, particularly in suburban areas. This study evaluates the feasibility and safety of using drones to deliver AEDs in suburban OHCA scenarios. A series of ninety test flights were conducted using a DJI Matrice 600 drone (DJI, China) to deliver a Philips HeartStart AED (Philips, Netherlands) across varying payloads. Bystanders in simulated OHCA situations identified their location via mobile applications, enabling the drone operator to dispatch the drone beyond the pilot's line of sight. The results showed a 97.7% success rate in AED delivery, with a median flight distance of 4042 m and a median response time of 7 min and 39 s. Despite payload variations, the drone maintained adequate speed and landing accuracy, with a mean speed of 9.17 m per second and a median landing error of 122 centimeters. The findings suggest that drones have significant potential for improving emergency medical responses in suburban areas of developing countries. Integration into emergency services could address current delays, though further research is necessary to optimize performance under varying conditions.

Automated loss of pulse detection on a consumer smartwatch

Out-of-hospital cardiac arrest is a time-sensitive emergency that requires prompt identification and intervention: sudden, unwitnessed cardiac arrest is nearly unsurvivable1-3. A cardinal sign of cardiac arrest is sudden loss of pulse4. Automated biosensor detection of unwitnessed cardiac arrest, and dispatch of medical assistance, may improve survivability given the substantial prognostic role of time3,5, but only if the false-positive burden on public emergency medical systems is minimized5-7. Here we show that a multimodal, machine learning-based algorithm on a smartwatch can reach performance thresholds making it deployable at a societal scale. First, using photoplethysmography, we show that wearable photoplethysmography measurements of peripheral pulselessness (induced through an arterial occlusion model) manifest similarly to pulselessness caused by a common cardiac arrest arrhythmia, ventricular fibrillation. On the basis of the similarity of the photoplethysmography signal (from ventricular fibrillation or arterial occlusion), we developed and validated a loss of pulse detection algorithm using data from peripheral pulselessness and free-living conditions. Following its development, we evaluated the end-to-end algorithm prospectively: there was 1 unintentional emergency call per 21.67 user-years across two prospective studies; the sensitivity was 67.23% (95% confidence interval of 64.32% to 70.05%) in a prospective arterial occlusion cardiac arrest simulation model. These results indicate an opportunity, deployable at scale, for wearable-based detection of sudden loss of pulse while minimizing societal costs of excess false detections7.

Impaired consciousness due to hypermagnesemia associated with stercoral colitis: report of a rare case

BACKGROUND

Hypermagnesemia is a rare electrolyte abnormality that is difficult to diagnose because its symptoms are nonspecific. In addition to magnesium administration, renal dysfunction is often a major risk factor associated with the condition; severe intestinal dysfunction is also a known risk factor. However, no cases of hypermagnesemia were observed in the absence of magnesium administration.

CASE PRESENTATION

A 75-year-old woman with cognitive impairment presented to the emergency department with impaired consciousness. The patient was comatose and hypotensive and had a markedly distended abdomen. Her blood pressure was stabilized with infusion; however, the improvement in consciousness was insufficient and somnolence continued. Abdominal computed tomography revealed marked colonic distension due to fecal impaction in the rectum, with wall thickening and pericolonic fat stranding. Blood tests revealed elevated levels of C-reactive protein (10.2 mg/dL), lactate (6.04 mmol/L), and magnesium (5.9 mg/dL). There was no history of ingestion of magnesium-containing preparations; thus, the patient was diagnosed with hypermagnesemia associated with stercoral colitis. Magnesium levels and consciousness improved with the administration of calcium preparations, diuretics, antibiotics, and defecation control.

CONCLUSIONS

Severe bowel dysfunction can cause hypermagnesemia, even in the absence of magnesium administration.

Trapped in the NETs: Multiple Roles of Platelets in the Vascular Complications Associated with Neutrophil Extracellular Traps

Neutrophil extracellular traps (NETs) have received significant attention in recent years for their role in both the immune response and the vascular damage associated with inflammation. Platelets have been described as critical components of NETs since the initial description of this physio-pathological response of neutrophils. Platelets have been shown to play a dual role as responders and also as stimulators of NETs. The direct interaction with DNA leads to the entrapment of platelets into NETs, a phenomenon that significantly contributes to the thrombotic complications of inflammation and neutrophil activation, while the direct and paracrine stimulation of neutrophils by platelets has been shown to initiate the process of NET formation. In this review, we provide a comprehensive description of our current understanding of the molecular mechanisms underlying the entrapping of platelets into NETs and, in parallel, the platelet-driven cellular responses promoting NET formation. We then illustrate established examples of the contribution of NETs to vascular pathologies, describe the important questions that remain to be answered regarding the contribution of platelets to NET formation and NET-dependent cardiovascular complication, and highlight the fundamental steps taken towards the application of our understanding of platelets' contribution to NETs for the development of novel cardiovascular therapies.

Care of the chronic dialysis patient in the intensive care unit: a state-of-the-art review

Chronic dialysis patients account for a high proportion of intensive care unit admissions. The prevalent dialysis population is growing worldwide, accompanied by increasing medical complexity and comorbidities. Critical care physicians must be familiar with the unique clinical characteristics of this patient group. There is relatively little evidence specifically concerning the assessment and treatment of critically unwell individuals on long-term dialysis. This narrative review explores the approach to the management of chronic dialysis patients in the intensive care unit.

Cost-effectiveness Analysis of Nirmatrelvir/Ritonavir Compared with Molnupiravir in Patients at High Risk for Progression to Severe COVID-19 in Japan

Background: Nirmatrelvir/ritonavir (NMV/r) and molnupiravir are oral antiviral drugs approved for the treatment of early symptomatic patients with mild to moderate COVID-19 at high risk of progression to severe disease in Japan. Objective: This study evaluated, from a Japanese payer perspective, the cost-effectiveness of NMV/r compared with molnupiravir among patients with COVID-19. Methods: This cost-effectiveness model describes the COVID-19 disease history and the impact of antiviral treatment on short-term and long-term outcomes. Nirmatrelvir/ritonavir was compared with molnupiravir, and in the scenario analysis NMV/r was compared with standard of care over a lifetime horizon. Results: When compared with molnupiravir, NMV/r showed higher quality-adjusted life years (QALYs) (15.752 vs 15.739) and higher total cost (¥6 248 014 vs ¥6 245 829 [US 44   136.86 v s 44 121.42]). The incremental cost-effectiveness ratio was ¥164 934 (US 1165.12 ) p e r Q A L Y g a i n e d , w h i c h w a s l o w e r t h a n t h e w i l l i n g n e s s - t o - p a y ( W T P ) t h r e s h o l d i n J a p a n ( ¥ 5   000   000 / Q A L Y [ U S 35 320.71/QALY]). In the scenario analysis, the incremental cost-effectiveness ratio was ¥3 646 821 (US 25   761.66 ) p e r Q A L Y g a i n e d . O n e - w a y s e n s i t i v i t y a n a l y s i s a n d p r o b a b i l i s t i c s e n s i t i v i t y a n a l y s i s s h o w e d t h a t N M V / r w a s c o s t - e f f e c t i v e c o m p a r e d w i t h m o l n u p i r a v i r a n d s t a n d a r d o f c a r e c o n s i s t e n t l y . A l l r e s u l t s o f o n e - w a y s e n s i t i v i t y a n a l y s i s s h o w e d t h a t t h e i n c r e m e n t a l c o s t - e f f e c t i v e n e s s r a t i o s w e r e b e l o w t h e W T P t h r e s h o l d i n J a p a n . T h e r e s u l t o f t h e c o s t - e f f e c t i v e n e s s a c c e p t a b i l i t y c u r v e s h o w e d t h a t t h e p r o b a b i l i t y t h a t t h e i n c r e m e n t a l c o s t - e f f e c t i v e n e s s r a t i o w a s b e l o w t h e W T P o f ¥ 5   000   000 / Q A L Y ( U S 35 320.71/QALY) was 100.00%. Conclusion: Nirmatrelvir/ritonavir is cost-effective compared with molnupiravir and standard of care from a Japanese payer perspective. This study provides evidence for the cost-effectiveness of NMV/r for patients with COVID-19.

Artificial intelligence applied to electrocardiogram to rule out acute myocardial infarction: the ROMIAE multicentre study

BACKGROUND AND AIMS

Emerging evidence supports artificial intelligence-enhanced electrocardiogram (AI-ECG) for detecting acute myocardial infarction (AMI), but real-world validation is needed. The aim of this study was to evaluate the performance of AI-ECG in detecting AMI in the emergency department (ED).

METHODS

The Rule-Out acute Myocardial Infarction using Artificial intelligence Electrocardiogram analysis (ROMIAE) study is a prospective cohort study conducted in the Republic of Korea from March 2022 to October 2023, involving 18 university-level teaching hospitals. Adult patients presenting to the ED within 24 h of symptom onset concerning for AMI were assessed. Exposure included AI-ECG score, HEART score, GRACE 2.0 score, high-sensitivity troponin level, and Physician AMI score. The primary outcome was diagnosis of AMI during index admission, and the secondary outcome was 30 day major adverse cardiovascular event (MACE).

RESULTS

The study population comprised 8493 adults, of whom 1586 (18.6%) were diagnosed with AMI. The area under the receiver operating characteristic curve for AI-ECG was 0.878 (95% CI, 0.868-0.888), comparable with the HEART score (0.877; 95% CI, 0.869-0.886) and superior to the GRACE 2.0 score, high-sensitivity troponin level, and Physician AMI score. For predicting 30 day MACE, AI-ECG (area under the receiver operating characteristic, 0.866; 95% CI, 0.856-0.877) performed comparably with the HEART score (0.858; 95% CI, 0.848-0.868). The integration of the AI-ECG improved risk stratification and AMI discrimination, with a net reclassification improvement of 19.6% (95% CI, 17.38-21.89) and a C-index of 0.926 (95% CI, 0.919-0.933), compared with the HEART score alone.

CONCLUSIONS

In this multicentre prospective study, the AI-ECG demonstrated diagnostic accuracy and predictive power for AMI and 30 day MACE, which was similar to or better than that of traditional risk stratification methods and ED physicians.

Phenotypes of Functional Decline or Recovery in Sepsis ICU Survivors: Insights From a 1-Year Follow-Up Multicenter Cohort Analysis

OBJECTIVE

Sepsis often leads to heterogeneous symptoms of post-intensive care syndrome (PICS) composing physical, cognitive, and psychiatric disabilities, resulting in deteriorated quality of life (QoL), with limited interventions. This study aimed to identify phenotypes of sepsis-associated PICS by physical, cognitive, and psychiatric function and QoL at hospital discharge.

DESIGN

A prospective observational study.

SETTING

Twenty-one mixed ICUs.

PATIENTS

All consecutive adult patients between November 2020 and April 2022, diagnosed with sepsis at ICU admissions and survived discharge, were enrolled.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Phenotyping with clusters determined by three approaches was performed with following variables at hospital discharge: Barthel Index (≤ 90 defined physical PICS), Short Memory Questionnaire (< 40 defined cognitive PICS), Hospital Anxiety and Depression Scale (≥ 8 defined psychiatric PICS), Impact of Event Scale-Revised (≥ 25 defined psychiatric PICS), EuroQoL 5-dimension 5-level, Clinical Frailty Scale hand-grip strength, and Medical Research Council. Each disability, employment, destination, and survival, were followed over the first year of hospital discharge. In total, 220 ICU patients were included (median age: 72.5 yr, 129 males (59%), 166 septic shocks (75%), and median Sequential Organ Failure Assessment Score: 8). Four phenotypes were identified: group 1 (n = 62) with no PICS, group 2 (n = 55) with mild PICS (physical and cognitive), group 3 (n = 53) with moderate PICS (all domains), and group 4 (n = 50) with severe PICS (all domains). Functional decline and recovery significantly varied among the phenotypes. Physical and cognitive PICS in group 2 improved by the 3-month follow-up, whereas the disabilities in groups 3 and 4 remained over the year. Psychiatric PICS in groups 3 and 4 ameliorated, whereas depression symptoms in group 4 were still evident at the 12-month follow-up. All groups showed persistent moderate to severe reduced QoL and low employment (0-50%). The survival in group 4 continuously decreased.

CONCLUSIONS

Four clinical phenotypes of ICU sepsis survivors might contribute to a deeper understanding of post-sepsis trajectories and an individualized treatment approach.

Quality of guidelines for infection management in sepsis: a critical appraisal using the AGREE II instrument

OBJECTIVES

The aim of this study was to systematically assess the methodological quality of current sepsis infection management guidelines and identify gaps in knowledge that limit evidence-based practice.

METHODS

A systematic search was conducted to obtain guidelines for the management of sepsis infections (2012-2021), and three reviewers independently assessed the quality of eligible guidelines using Appraisal of Guidelines for Research and Evaluation (AGREE II) tool. The intraclass correlation coefficients (ICCs) were used to measure the agreement between reviewers. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach was used to analyze the strength of recommendation and level of evidence of the guideline, and the number of recommendations, strength of recommendation, and level of evidence were determined.

RESULTS

Eleven guidelines for the management of sepsis infection were identified. An overall high agreement among the evaluators for each domain was observed (ICC ranged from 0.850 to 0.959). The overall scores of the included guidelines were all over 60% (range, 62.3-89.90%), which were worthy of recommendation for clinical use; among them, 4 guidelines had an overall score of over 80%, which were high-quality guideline articles. In terms of the quality domains of the guidelines, the scope and purpose domain and the clarity of expression domain had the highest average scores, which were 93.6% (range, 79.6-98.1%) and 91.4% (range, 64.8-98.1%), respectively, while the applicability domain had the lowest average score, which was 64.8% (range, 51.4-76.4%). The strength of the recommendations of the guideline recommendations was mainly weak, accounting for 73.4%; the level of evidence cited was mainly very low quality (60.2%) and low quality (28.1%).

CONCLUSIONS

The quality of sepsis infection management guidelines varies, but the overall quality level is satisfactory. Improving the low-quality areas of sepsis guidelines, attempting to resolve existing problems and controversies, and improving the quality of research evidence will be effective ways for developers to upgrade sepsis guidelines.

Association Between Response Time and Time from Emergency Medical Service Contact with the Patient to Hospital Arrival as well as Survival and Neurological Outcomes in Pediatric Out-of-Hospital Cardiac Arrest

OBJECTIVES

In out-of-hospital cardiac arrest (OHCA), prehospital time is crucial and can be divided into response time, from emergency call to emergency medical service (EMS) contact, and time from EMS contact to hospital arrival. To improve prehospital strategies for pediatric OHCA, it is essential to understand the association between these time intervals and patient outcomes; however, detailed investigations are lacking. The current study aimed to examine the association between response time and time from EMS contact to hospital arrival as well as survival and neurological outcomes in pediatric OHCA.

METHODS

This nationwide retrospective analysis used data from an OHCA registry in Japan between June 2014 and December 2021. Pediatric patients aged <18 years who had OHCA were included in the analysis. The primary outcome was 1-month survival, and the secondary outcome was 1-month favorable neurological outcome. Generalized additive model analyses and logistic regression analyses, adjusted for confounders, were performed to examine the non-linear and linear relationship between response time and patient care time (time from EMS contact with the patient to hospital arrival) and outcomes, respectively.

RESULTS

In the generalized additive model analyses of response time, both survival and neurological outcomes worsened with response time, with outcomes appearing to further decline with a response time of approximately 15 min. On the other hand, there was a linear association between patient care time as well as 1-month survival and favorable neurologic outcomes. In logistic regression analyses, shorter response times were significantly associated with survival (odds ratio [OR]: 0.83, 95% confidence interval [CI]: 0.79-0.91]) and a favorable neurological outcome (OR: 0.75, 95% CI: 0.59-0.93). In contrast, time from EMS contact to hospital arrival was not significantly associated with survival (OR: 0.99, 95% CI: 0.97-1.02) and favorable neurological outcomes (OR: 1.02, 95% CI: 0.97-1.07).

CONCLUSIONS

A response time of <15 min can be associated with better survival and neurological outcomes. However, there is no significant association between time from EMS contact to hospital arrival as well as survival and favorable neurological outcomes.

Deaths from Angioedema-Anaphylaxis and Covid-19

Angioedema is non-dependent, non-pitting edema at a variety of sites. Its forms can be divided into histamine-mediated and bradykinin-mediated types. Histamine-mediated forms can present similarly to anaphylaxis with urticaria and itching, while bradykinin-mediated angioedema is slower in onset, presents with greater facial oropharyngeal involvement, and has a higher risk of progression. Bradykinin-mediated angioedema is of particular importance as it will not respond to the usual medications used in histamine-mediated anaphylaxis (steroids, antihistamines, epinephrine, etc). In this report, we present two cases of angioedema-induced death with coexisting COVID-19 infections in two male decedents. The associated gross autopsy, histology, and laboratory values will be discussed in detail. This article will highlight the importance of early detection and adequate treatment for the type of angioedema being evaluated as well as a discussion regarding the relationship between COVID-19 and angioedema.

Muhammadiyah's COVID-19: Combining Islamic, Psychological, and Medical Approach in Indonesia

COVID-19 patients in self-isolation tended to be ignored and marginalized. This marginalization then results in fear, anxiety, depression, stress, trauma, and even suicidal tendency. During self-isolation, patients are only treated medically but their psychological and spiritual aspects are often abandoned. Hence, a more holistic approach is necessary to treat COVID-19 patients while they are in self-isolation. The present study aims to explain the self-isolation model in Muhammadiyah COVID-19 Pesantren in Indonesia as a comprehensive model with holistic, religious, spiritual, and psychological approaches. This research is a qualitative research. The research involved fifty respondents comprising founding spiritual figures of the Muhammadiyah COVID-19 Pesantrens, doctors and medical staff, psychologists, and COVID-19 survivors. The data were collected through observation, documentation, and interviews. Data analysis was conducted through data display, reduction, categorization, and interpretation. The research findings show that the Muhammadiyah COVID-19 Pesantren integrates the Islamic educational aspect and COVID-19 hospital concepts. The treatment through the three approaches resulted in the increased health of the COVID-19 patients. It is expected that the combination of spiritual, psychological, and medical approaches during the COVID-19 pandemic can be adapted to mitigate other diseases, such as TBC, HIV, or similar pandemics post COVID-19.

Out-of-hospital cardiac arrest event after cancer diagnosis: a korean metropolitan cohort study

BACKGROUND

The importance of assessing out-of-hospital cardiac arrest (OHCA) risk in cancer patients is increasing as cancer incidence rises in aging populations.

OBJECTIVE

This study aimed to investigate the association between newly diagnosed cancer and OHCA risk using a metropolitan cohort from South Korea.

METHODS

A population-based retrospective cohort study was conducted, linking the nationwide OHCA registry with the National Health Information Database. The study included adults aged 40 years or older, residing in Seoul between 2015 and 2018, with no history of cancer or OHCA. The main exposure was cancer development. The primary outcome was the occurrence of OHCA with medical cause. Adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) were calculated using a cause-specific hazard model considering death as a competing risk. Analyses stratified by age group and cancer type were also conducted.

RESULTS

During a follow-up period of up to 4 years for 5,450,438 individuals, 174,785 participants developed cancer. The incidence rates of OHCA per 100,000 person-years were 54.0 in non-cancer and 145.0 in cancer groups, respectively. The aHR (95% CI) for OHCA associated with cancer development was 3.18 (2.97-3.41). The aHR (95% CI) for OHCA was highest in the 40-49 years of age group (7.52 [5.52-10.25]), followed by 50-59 years old (6.66 [5.56-7.97]) compared to older age groups. By cancer type, pancreatic, lung, biliary tract, and liver cancer were associated with a significantly increased risk of OHCA.

CONCLUSION

We found an association between newly diagnosed cancer and the occurrence of OHCA. Our findings underscore the importance of tailored risk assessments and proactive care planning for patients with cancer.

Development and validation of interpretable machine learning models for triage patients admitted to the intensive care unit

OBJECTIVES

Developing and validating interpretable machine learning (ML) models for predicting whether triaged patients need to be admitted to the intensive care unit (ICU).

MEASURES

The study analyzed 189,167 emergency patients from the Medical Information Mart for Intensive Care IV database, with the outcome being ICU admission. Three models were compared: Model 1 based on Emergency Severity Index (ESI), Model 2 on vital signs, and Model 3 on vital signs, demographic characteristics, medical history, and chief complaints. Nine ML algorithms were employed. The area under the receiver operating characteristic curve (AUC), F1 Score, Positive Predictive Value, Negative Predictive Value, Brier score, calibration curves, and decision curves analysis were used to evaluate the performance of the models. SHapley Additive exPlanations was used for explaining ML models.

RESULTS

The AUC of Model 3 was superior to that of Model 1 and Model 2. In Model 3, the top four algorithms with the highest AUC were Gradient Boosting (0.81), Logistic Regression (0.81), naive Bayes (0.80), and Random Forest (0.80). Upon further comparison of the four algorithms, Gradient Boosting was slightly superior to Random Forest and Logistic Regression, while naive Bayes performed the worst.

CONCLUSIONS

This study developed an interpretable ML triage model using vital signs, demographics, medical history, and chief complaints, proving more effective than traditional models in predicting ICU admission. Interpretable ML aids clinical decisions during triage.

Effect of ultrasonic burst microbubbles on microwave coagulation hemostasis in a pig model of hepatic hemorrhage

To investigate the hemostatic efficacy of ultrasound in flash mode and/or microbubbles-assisted microwave coagulation for active liver hemorrhage. Thirty miniature pigs were randomly divided into five groups. Active hepatic hemorrhage was induced under ultrasound guidance. Treatment groups included microwave ablation (MWA), microbubbles with microwave ablation (MBs + MWA), ultrasound in flash mode with microwave ablation (Flash + MWA), ultrasound in flash mode with microbubbles and microwave ablation (Flash + MBs + MWA), and ultrasound in flash mode with phosphate-buffered saline and microwave ablation (Flash + PBS + MWA). Hemostasis time, blood tests, ultrasound, pathological inspections, and analysis were conducted. The Flash + MBs + MWA group showed the shortest hemostasis time, with 2.25 ± 0.45, 2.42 ± 0.51, and 5.50 ± 0.52 min for diaphragm, gallbladder, and hepatic artery bleeding. Highest blood cell stability and a significantly larger hemostatic lesion range were observed in this group on ultrasound. Pathological analysis revealed varied extents of liver sinus congestion and dilation. The combination of ultrasound contrast microbubbles system and microwave thermal coagulation can effectively treat active hepatic hemorrhage, and microbubbles in ultrasound Flash mode have an enhancing effect on microwave coagulation hemostasis.

Impacts of long-term nasogastric tube feeding and tracheostomy on pharyngeal and laryngeal structure in ABI patients: an FEES study

OBJECTIVES

To investigate the characteristics of pharyngeal and laryngeal structure in patients with acquired brain injury (ABI), who were long time wearing nasogastric tube (NGT) with or without tracheostomy.

METHODS

103 ABI patients with NGT indwelled for more than 1 month were retrospectively studied and divided into two groups by whether or not undergoing tracheostomy. Age, gender, types of brain injury, course of the disease, disorders of consciousness, activities of daily living (ADL) and fiberoptic endoscopic examination of swallowing (FEES) were evaluated. The structure and function of pharyngeal and laryngeal were assessed by FEES, focusing on the morphology of the arytenoid cartilage, epiglottis, vocal folds, tongue base, and pharyngeal cavity.

RESULTS

Prolonged indwelling nasogastric tubes and tracheostomy tubes might lead to abnormal alterations of the structure and function in the arytenoid cartilage, epiglottis, tongue base, and pharyngeal cavity. Epiglottis shape abnormality, glossoptosis and pharyngeal stenosis were present in a larger proportion of the NGT-TRACH (nasogastric tube with tracheostomy) group than the NGT group (p < 0.05).

CONCLUSIONS

This study highlights potential physiological changes associated with prolonged placement of nasogastric tubes and tracheostomy tubes, which could impede the recovery of swallowing function and decannulation. We hope to provide valuable evidence to develop effective management strategies for ABI patients with NGT or tracheostomy.

Electrical impedance tomography to set positive end-expiratory pressure

PURPOSE OF REVIEW

To summarize the rationale and concepts for positive end-expiratory pressure (PEEP) setting with electrical impedance tomography (EIT) and the effects of EIT-based PEEP setting on cardiopulmonary function.

RECENT FINDINGS

EIT allows patient-specific and regional assessment of PEEP effects on recruitability and overdistension, including its impact on ventilation-perfusion (V̇/Q) mismatch. The overdistension and collapse (OD-CL) method is the most used EIT-based approach for PEEP setting. In the RECRUIT study of 108 COVID-19 ARDS patients, the PEEP level corresponding to the OD-CL crossing point showed low overdistension and collapse (below 10% and 5%, respectively) regardless of recruitability. In a porcine model of acute respiratory distress syndrome (ARDS), it was shown that at this crossing point, respiratory mechanics (compliance, ΔP) were consistent, with adequate preload, lower right ventricular afterload, normal cardiac output, and sufficient gas exchange. A recent meta-analysis found that EIT based PEEP setting improved lung mechanics and potentially outcomes in ARDS patients. EIT thus provides critical insights beyond respiratory mechanics and oxygenation for individualized PEEP optimization. EIT-based methods for PEEP setting during assisted ventilation have also been proposed.

SUMMARY

EIT is a valuable technique to guide individualized PEEP setting utilizing cardiopulmonary information that is not captured by respiratory mechanics and oxygenation response alone.

Comparing the effects of magnesium sulfate and lidocaine spray on hemodynamic changes caused by laryngoscopy and tracheal intubation: a randomized clinical trial

AIM

This study aims at comparing the impact of Magnesium Sulfate and Lidocaine sprays on hemodynamic changes after laryngoscopy and tracheal intubation.

DESIGN

This double-blind clinical trial (code IRCT20230719058846N1) was conducted on the patients undergoing elective surgery in the city of Karaj.

METHODS

A total of 100 patients, aged 18 to 40 years and classified as ASA I or II, who were candidates for elective surgery, were randomly assigned to two equal groups. Prior to intubation, patients received lidocaine spray (5 puffs of Lidocaine 10%) in one group, and magnesium sulfate spray (5 puffs of Magnesium 20%) in the other. Induction of anesthesia was the same in both groups. Patients' hemodynamic statuses were measured and compared once before the intubation and also 1, 3, 5, 7 and 10 min after it.

RESULTS

Before the intervention, there was no statistically significant difference between the two groups in terms of demographic and hemodynamic variables (P < 0.05). The results showed that the systolic blood pressure at minutes 3, 5, and 7 was significantly lower among the patients receiving magnesium than those receiving lidocaine (P < 0.05). Other hemodynamic variables were not statistically different between the two groups (P < 0.05).

CONCLUSION

Based on the findings of the present study, magnesium sulfate spray is more effective than lidocaine in controlling hemodynamic complications. Therefore, it can be used to reduce hemodynamic complications following intubation. However, it may be associated with tachycardia, which needs to be taken into account.

Effects of Long COVID in Patients with Severe Coronavirus Disease 2019 on Long-Term Functional Impairments: A Post Hoc Analysis Focusing on Patients Admitted to the ICU in the COVID-19 Recovery Study II

Background/Objectives: This study investigated the prevalence of functional impairments and the effects of long COVID on long-term functional impairments in patients with severe COVID-19. Methods: We conducted a nationwide multicenter cohort study in collaboration with nine hospitals, collecting data using self-administered questionnaires from participants aged 20 years or older who were diagnosed with COVID-19, admitted to the intensive care unit (ICU) between April 2021 and September 2021, and discharged alive. Questionnaires regarding daily life, sequela, and functional impairments were mailed to patients in August 2022. The effects of long COVID on functional impairments were examined using a multivariate logistic regression analysis. Results: The survey was completed by 220 patients, with a mean of 416 days after discharge. Among respondents, 20.5% had physical impairments (n = 45), 35.0% had mental disorders (n = 77), and 42.7% had either (n = 94). Furthermore, 77.7% had long COVID (171/220), and the most common symptom was dyspnea (40.0%). The multivariate analysis showed that fatigue/malaise, upper respiratory tract symptoms, myalgia, muscle weakness, decreased concentration, sleep disorder, brain fog, and dizziness were risk factors for functional impairments at one year. Conclusions: Many patients with severe COVID-19 admitted to the ICU still suffered from post-intensive care syndrome even after one year, which manifested in combination with direct symptoms of the original disease, such as long COVID.

Dysbiosis of Oral Microbiome: A Key Player in Oral Carcinogenesis? A Critical Review

The oral cavity is known to harbor hundreds of microorganisms, belonging to various genera, constituting a peculiar flora called the oral microbiome. The change in the relative distribution of the constituents of this microbial flora, due to any reason, leads to oral dysbiosis. For centuries, oral dysbiosis has been linked to the etiopathogenesis of several medical illnesses, both locally and systemically-. However, aided by the recent advent of bio-technological capabilities, several reports have re-emerged that link oral dysbiosis to oral carcinogenesis, and numerous studies are currently exploring their association and plausible mechanisms. Some of the proposed mechanisms of oral dysbiosis-induced carcinogenesis (ODIC) include-a bacteria-induced chronic inflammatory state leading to direct cellular damage, inflammatory-cytokine-mediated promotion of cellular proliferation and invasion, release of bacterial products that are carcinogenic, and suppression of local immunity by alteration of the tumor microenvironment. However, the actual interactions between these cellular mechanisms and their role in carcinogenesis are not yet fully understood. This review provides a comprehensive overview of the various hypotheses and mechanisms implicated in the ODIC, along with the corresponding molecular aberrations. Apart from discussing the usual constituents of the oral microbiome profile, the review also summarizes the various dysbiosis profiles implicated in ODIC. The review also sheds light on the potential clinical implications of the research on oral microbiome in the prevention and management of oral cancer.

The feasibility of point-of-care testing for initial urinary liver fatty acid-binding protein to estimate severity in severe heatstroke

Rapid assessment of severity is crucial for timely intervention and improved patient outcomes in heatstroke (HS). However, existing biomarkers are limited in their accuracy and accessibility in ER settings. A prospective pilot study was conducted to assess urinary liver fatty acid-binding protein (L-FABP) levels using a point-of-care testing (POCT) upon HS. Severity was estimated using initial Sequential Organ Failure Assessment (SOFA) scores, and outcomes were measured using modified Rankin Scale (mRS) scores. In 78 severe HS patients, semi-quantitative L-FABP measurements were performed in ER and patients were divided as P-group (positive group, L-FABP ≧ 12.5 ng/mL on POCT) and N-group (negative group: L-FABP < 12.5ng/mL, on POCT). urinary L-FABP concentrations were also measured on admission, with a median concentration of 48.3 ng/mL. The positive correlation was observed between urinary L-FABP concentration and pulse rate (r = 0.300, P < 0.01) and lactate (r = 0.259, P < 0.01). The POCT of L-FABP showed promise in predicting severity, as indicated by higher concentrations in patients with higher initial SOFA scores. Furthermore, the comparison between semi-quantitative POCT measurements and urine concentrations of L-FABP measured by enzyme-linked immunosorbent assay (ELISA) revealed significant differences among three POCT groups (POC Range < 12.5 ng/ml, 12.6-100 ng/ml, and 55 > 100 ng/ml, P = 0.001). Additionally, patients in the POCT positive group had significantly worse outcomes at discharge compared to the negative group, although this difference diminished over time. The study demonstrates the feasibility and potential utility of POCT for initial L-FABP in estimating severity in HS patients. This rapid and accessible testing method may aid in early field triage and intervention, ultimately improving patient outcomes in the management of HS.

Biphasic anaphylaxis in a Canadian tertiary care centre: an evaluation of incidence and risk factors from electronic health records and telephone interviews

BACKGROUND

Our previous 2007 study reported a 19.4% rate of biphasic anaphylaxis in Kingston, Ontario. Since then, few updates have been published regarding the etiology and risk factors of biphasic anaphylaxis. This study aimed to describe the incidence of and predictors of biphasic anaphylaxis in a single centre through a retrospective evaluation of patients with diagnosed anaphylaxis.

METHODS

From November 2015 to August 2017, all patients who presented to the emergency department at two hospital sites in Kingston given a diagnosis of "allergic reaction," "anaphylaxis," "drug allergy," or "insect sting allergy," were evaluated. Patients were contacted sometime after ED discharge to obtain consent and confirm symptoms and timing of the reaction. A trained allergist determined if criteria for anaphylaxis were met and categorized the reactions as being uniphasic, biphasic, or non-anaphylactic biphasic. A full medical review of the event ensued, and each type of anaphylactic event was statistically compared.

RESULTS

Of 138 anaphylactic events identified, 15.94% were biphasic reactions, 79.0% were uniphasic, and 5.07% were classified alternatively as a non-anaphylactic biphasic reaction. The average time of a second reaction was 19.0 h in patients experiencing biphasic reactivity. For biphasic anaphylaxis, the symptom profiles of second reactions were significantly less severe (p = 0.0002) compared with the initial reaction but significantly more severe than non-anaphylactic biphasic events (p < 0.0001).No differences of management were identified between events.

CONCLUSION

The incidence of biphasic reactions in this cohort was 15.94% and the average second-phase onset was 19.0 h. In biphasic reactivity, it appears that the symptom profile second reaction is less severe compared to the first reaction.

Protective Effects of BPC 157 on Liver, Kidney, and Lung Distant Organ Damage in Rats with Experimental Lower-Extremity Ischemia-Reperfusion Injury

Background and Objectives: Ischemia-reperfusion (I/R) injury can affect multiple distant organs following I/R in the lower extremities. BPC-157's anti-inflammatory and free radical-neutralizing properties suggest its potential in mitigating ischemia-reperfusion damage. This study evaluates the protective effects of BPC-157 on remote organ damage, including the kidneys, liver, and lungs, in a rat model of skeletal muscle I/R injury. Materials and Methods: A total of 24 male Wistar albino rats were randomly divided into four groups: sham (S), BPC-157(B), lower extremity I/R(IR) and lower extremity I/R+BPC-157(I/RB). Some 45 min of ischemia of lower extremity was followed by 2 h of reperfusion of limbs. BPC-157 was applied to groups B and I/RB at the beginning of the procedure. After 2 h of reperfusion, liver, kidney and lung tissues were harvested for biochemical and histopathological analyses. Results: In the histopathological examination, vascular and glomerular vacuolization, tubular dilation, hyaline casts, and tubular cell shedding in renal tissue were significantly lower in the I/RB group compared to other groups. Lung tissue showed reduced interstitial edema, alveolar congestion, and total damage scores in the I/RB group. Similarly, in liver tissue, sinusoidal dilation, necrotic cells, and mononuclear cell infiltration were significantly lower in the I/RB group. Additionally, the evaluation of TAS, TOS, OSI, and PON-1 revealed a statistically significant increase in antioxidant activity in the liver, lung, and kidney tissues of the I/RB group. Conclusions: The findings of this study demonstrate that BPC-157 exerts a significant protective effect against distant organ damage in the liver, kidneys, and lungs following lower extremity ischemia-reperfusion injury in rats.

Examining recovery trajectories of physical function, activity performance, cognitive and psychological functions, and health related quality of life in COVID-19 patients treated in ICU: a Swedish prospective cohort study

PURPOSE

To investigate the recovery trajectories of physical function, activity performance, cognitive and psychological functions, and health related quality of life, as well as potential interaction effects, in individuals with COVID-19 treated in an intensive care unit (ICU).

METHODS

This prospective cohort study included patients with confirmed COVID-19 infection, treated in an ICU. Clinical assessments and self-ratings of functioning, disability and health were performed > 1 month and > 12 months after discharge from hospital.

RESULTS

Among the 65 included individuals (mean age 56.6, SD 11) significant improvements in physical and psychological function were observed over time, although not reaching population norms. Cognition remained unchanged (MoCA median 27, IQR 4). At the 12-month follow-up, physical limitations in activity (RAND-36) were found to be associated with dyspnea (mMRC-Dyspnea), mental and physical fatigue (MFI-20), and walking endurance (6-minute walk test) (r2 0.509 p < 0.001). Role limitations due to physical health (RAND-36) was found to be associated with physical and mental fatigue (MFI-20) and pain (r2 0.530 p < 0.001).

CONCLUSION

Despite improvements in functioning and health in this group of predominantly younger age recovery did not reach population norms. These results highlight persistent impairments and activity limitations that may necessitate long-term healthcare interventions.

Chromatographic Methods for the Analysis of the Antipsychotic Drug Clozapine and Its Major Metabolites: A Review

Clozapine (CLZ), a second-generation antipsychotic, can effectively reduce schizophrenia, bipolar disorder and major depression symptoms. This review provides an overview of all reported chromatographic methods (62 references) for the quantification of CLZ and its two main metabolites, norclozapine and clozapine N-oxide in pharmaceutical formulations, biological matrices and environmental samples.

Impact of underweight status on mortality in sepsis patients: a meta-analysis

Objective

The evidence regarding the impact of underweight status on clinical outcomes in patients with sepsis are still scarce and controversial. We aimed at conducting a meta-analysis to evaluate the potential associations between underweight and the mortality rate among sepsis patients.

Methods

A comprehensive electronic search was performed in PubMed, Cochrane Library, Embase, and Web of Science databases. Odds ratios (ORs) or mean differences and 95% confidence intervals (CIs) were calculated using RevMan 5.3.

Results

A total of 58,348 patients (normal weight group: 49,084 patients; underweight group: 9,264 patients) from 23 studies were included in this meta-analysis. The results indicated that the in-hospital mortality (OR, 1.28; 95% CI, 1.21, 1.35; heterogeneity: I 2 = 21%, P = 0.21), 28-day mortality (OR, 1.54; 95% CI, 1.26, 1.88; heterogeneity: I 2 = 74%, P < 0.0001) and 1-year mortality (OR, 1.78; 95% CI, 1.58, 2.00; heterogeneity: I 2 = 41%, P = 0.17) of underweight patients were significantly higher than those of normal weight patients. However, there was no significant difference in length of hospital stay or intensive care unit length of stay between underweight patients and normal-weight patients.

Conclusion

Underweight is associated with increased mortality in patients with sepsis. Physicians should pay more attention to the management of underweight sepsis patients.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=631417, identifier CRD42025631417.

Innovative nanoparticle-based approaches for modulating neutrophil extracellular traps in diseases: from mechanisms to therapeutics

Neutrophil extracellular traps (NETs) participate in both host defense and the pathogenesis of various diseases, such as infections, thrombosis, and tumors. While they help capture and eliminate pathogens, NETs' excessive or dysregulated formation can lead to tissue damage and disease progression. Therapeutic strategies targeting NET modulation have shown potential, but challenges remain, particularly in achieving precise drug delivery and maintaining drug stability. Nanoparticle (NP)-based drug delivery systems offer innovative solutions for overcoming the limitations of conventional therapies. This review explores the biological mechanisms of NET formation, their interactions with NPs, and the therapeutic applications of NP-based drug delivery systems for modulating NETs. We discuss how NPs can be designed to either promote or inhibit NET formation and provide a comprehensive analysis of their potential in treating NET-related diseases. Additionally, we address the current challenges and future prospects for NP-based therapies in NET research, aiming to bridge the gap between nanotechnology and NET modulation for the development of novel therapeutic approaches.

Two-year trajectory of functional recovery and quality of life in post-intensive care syndrome: a multicenter prospective observational study on mechanically ventilated patients with coronavirus disease-19

BACKGROUND

Post-intensive care syndrome (PICS) affects the quality of life (QOL) of survivors of critical illness. Although PICS persists for a long time, the longitudinal changes in each component and their interrelationships over time both remain unclear. This multicenter prospective study investigated the 2-year trajectory of PICS and its components as well as factors contributing to deterioration or recovery in mechanically ventilated patients with coronavirus disease 2019 (COVID-19), and also attempted to identify possible countermeasures.

METHODS

Patients who survived COVID-19 requiring mechanical ventilation completed questionnaires on the Barthel index, Short-Memory Questionnaire, Hospital Anxiety and Depression Scale, and EuroQol 5 dimensions 5-level every six months over a two-year period. Scores were weighted to account for dropouts, and the trajectory of each functional impairment was evaluated with alluvial diagrams. The prevalence of PICS and factors impairing or restoring function were examined using generalized estimating equations considering trajectories.

RESULTS

Among 334 patients, PICS prevalence rates in the four completed questionnaires were 72.1, 78.5, 77.6, and 82.0%, with cognitive impairment being the most common and lower QOL being noted when multiple impairments coexisted. Physical function and QOL indicated that many patients exhibited consistent trends of either recovery or deterioration. In contrast, cognitive function and mental health revealed considerable variability, with many patients showing fluctuating ratings in the later surveys. Delirium was associated with worse physical and mental health and poor QOL, while prolonged ventilation was associated with poor QOL. Living with family was associated with the recovery of all functions and QOL, while extracorporeal membrane oxygenation (ECMO) was associated with the recovery of cognitive function and mental health.

CONCLUSIONS

Critically ill patients had PICS for a long period and followed different trajectories for each impairment component. Based on trajectories, known PICS risk factors such as prolonged ventilation and delirium were associated with impaired recovery, while ECMO and the presence of family were associated with recovery from PICS. In critically ill COVID-19 patients, delirium management and family interventions may play an important role in promoting recovery from PICS.

TRIAL REGISTRATION NUMBER

UMIN000041276, August 01, 2020.