Protective effect of 5,4'-dihydroxy-6,8-dimethoxy7-O-rhamnosylflavone from Indigofera aspalathoides Vahl on lipopolysaccharide-induced intestinal injury in mice

Intestinal inflammation is one of the main health challenges affecting the quality of life of millions of people worldwide. Accumulating evidence introduces several flavonoids with multifaceted therapeutic properties in inflammatory diseases including intestinal inflammation. Herein, we examined potential anti-inflammatory properties of 5,4'-dihydroxy-6,8-dimethoxy7-O-rhamnosylflavone (DDR) flavone derived from Indigofera aspalathoides Vahl (I. aspalathoides Vahl) on lipopolysaccharide (LPS)-induced intestinal inflammation and injury in mice. Oral DDR treatment decreased serum levels of pro-inflammatory cytokines including TNF-α, IL-6, and IL-1β. It reduced oxidative stress through augmenting the activities of catalase (CAT) and superoxide dismutase (SOD) and reducing the level of malondialdehyde (MDA) in the duodenum and colon tissues. Moreover, DDR enhanced the activities of digestive enzymes including trypsin, pancreatic lipase, and amylase, and increased the production of short-chain fatty acids (SCFAs) by colon microbiota. Histopathological investigation of duodenum and colon revealed that DDR inhibited inflammatory infiltration and largely restored mucosal architecture and protected lining integrity. Importantly, DDR suppressed activation of nuclear factor-κB (NF-κB) signaling pathway through reduced expression of Toll-like receptor 4 (TLR4) and expression and phosphorylation of P65. The current study identified DDR as anti-inflammatory flavonoid capable of ameliorating LPS-induced intestinal inflammation through suppression of NF-κB signaling.

Systemic mechanisms of necrotic cell debris clearance

Necrosis is an overarching term that describes cell death modalities caused by (extreme) adverse conditions in which cells lose structural integrity. A guaranteed consequence of necrosis is the production of necrotic cell remnants, or debris. Necrotic cell debris is a strong trigger of inflammation, and although inflammatory responses are required for tissue healing, necrotic debris may lead to uncontrolled immune responses and collateral damage. Besides local phagocytosis by recruited leukocytes, there is accumulating evidence that extracellular mechanisms are also involved in necrotic debris clearance. In this review, we focused on systemic clearance mechanisms present in the bloodstream and vasculature that often cooperate to drive the clearance of cell debris. We reviewed the contribution and cooperation of extracellular DNases, the actin-scavenger system, the fibrinolytic system and reticuloendothelial cells in performing clearance of necrotic debris. Moreover, associations of the (mis)functioning of these clearance systems with a variety of diseases were provided, illustrating the importance of the mechanisms of clearance of dead cells in the organism.

Pragmatic approach to mobilizing individuals with critical illness due to COVID-19: clinical perspective

PURPOSE

To provide pragmatic guidance for acute rehabilitation management and implementation of early mobility for individuals with critical illness due to COVID-19.

METHODS

Clinical perspective developed through reflective clinical practice and narrative review of best available evidence.

RESULTS

Current clinical practice guidelines do not provide guidance for implementation of early mobility interventions for individuals with critical illness due to COVID-19 who require enhanced ventilatory support or support of inhaled pulmonary artery vasodilators. Many individuals who may benefit from implementation of early mobility interventions are excluded by strict interpretation of current guidelines.

CONCLUSIONS

Risk vs benefit of implementing early mobility interventions in individuals with critical illness due to COVID-19 can be mitigated through coordinated efforts of interdisciplinary teams to promote shared decision-making through therapeutic alliances with patients and their families. Clinicians must clearly define the goals of care, understand the limitations of monitoring equipment in the intensive care unit, prepare to titrate levels of oxygen based on an individual's physiologic response to mobility interventions, and help individuals maintain external goal-directed focus of attention to optimize outcomes of early mobility interventions.

Gasotransmitters and noble gases in cardioprotection: unraveling molecular pathways for future therapeutic strategies

Despite recent progress, ischemic heart disease poses a persistent global challenge, driving significant morbidity and mortality. The pursuit of therapeutic solutions has led to the emergence of strategies such as ischemic preconditioning, postconditioning, and remote conditioning to shield the heart from myocardial ischemia/reperfusion injury (MIRI). These ischemic conditioning approaches, applied before, after, or at a distance from the affected organ, inspire future therapeutic strategies, including pharmacological conditioning. Gasotransmitters, comprising nitric oxide, hydrogen sulfide, sulfur dioxide, and carbon monoxide, play pivotal roles in physiological and pathological processes, exhibiting shared features such as smooth muscle relaxation, antiapoptotic effects, and anti-inflammatory properties. Despite potential risks at high concentrations, physiological levels of gasotransmitters induce vasorelaxation and promote cardioprotective effects. Noble gases, notably argon, helium, and xenon, exhibit organ-protective properties by reducing cell death, minimizing infarct size, and enhancing functional recovery in post-ischemic organs. The protective role of noble gases appears to hinge on their modulation of molecular pathways governing cell survival, leading to both pro- and antiapoptotic effects. Among noble gases, helium and xenon emerge as particularly promising in the field of cardioprotection. This overview synthesizes our current understanding of the roles played by gasotransmitters and noble gases in the context of MIRI and cardioprotection. In addition, we underscore potential future developments involving the utilization of noble gases and gasotransmitter donor molecules in advancing cardioprotective strategies.

[Early source control of infection in patients seen in the emergency department: a systematic review]

OBJECTIVE

The term source (or focus) control encompasses all those physical measures that can be used to reduce the inoculum and modify those factors in the infectious medium that promote microbial growth or foreign antimicrobial defenses of the host. The main objective of this systematic review (SR) is to know and compare whether early detection and control of the focus (in less than 6 hours) in adult patients treated in the ED for severe infection or sepsis, compared to not controlling the focus or delayed focus control (more than 12 hours) is more effective and safer (improves clinical evolution, mortality, complications, hospital stay or need for ICU admission).

METHODS

A systematic review is carried out following the PRISMA regulations in the databases of PubMed, Web of Science, EMBASE, Lilacs, Cochrane, Epistemonikos, Tripdatabase and ClinicalTrials.gov from January 2000 to December 31, 2023 without language restrictions and using a combination of MESH terms: "Source Control", "Early" "Infection OR Bacterial Infection OR Sepsis", "Emergencies OR Emergency OR Emergency Department" and "Adults". Observational cohort studies were included. No meta-analysis techniques were performed, but results were compared narratively.

RESULTS

A total of 1,658 articles were identified, of which 2 that met the inclusion criteria and were classified as high quality were finally analyzed. The included studies represent a total of 2,404 patients with 678 cases in which an intervention was performed to control the focus (28.20%). In the first study, 28-day mortality was lower in patients who underwent an intervention to control the focus (12.3% vs. 22.5%; P <0.001), with an adjusted HR of 0.538 (95% CI: 0.389-0.744; P<0.001). In the second, it was demonstrated that the time elapsed from when the patient was evaluated for the first time and was hemodynamically stabilized, until the start of surgery was associated with his survival at 60 days with an OR of 0.31 (95% CI: 0.19-0.45; P <0.0001). In fact, for each hour of delay an adjusted OR of 0.29 (95% CI: 0.16-0.47; P<0.0001) is established. So if the intervention is performed before 2 hours at 60 days, 98% of the patients are still alive, if it is performed between 2-4 hours it is reduced to 78%, if it is between 4-6 hours it drops to 55%, but if it is done for more than 6 hours there will be no survivors at 60 days.

CONCLUSIONS

This review shows that source control carried out after the evaluation of patients attending the ED reduces short-term mortality (30-60 days) and that it would be advisable to implement any required source control intervention as soon as possible, ideally early (within 6 hours).

Renal Complications in Portal Hypertension

Acute kidney injury (AKI) is a common complication among patients with decompensated cirrhosis and its development is associated with worse prognosis in terms of survival. Patients with decompensated cirrhosis may develop a unique type of AKI, known as hepatorenal syndrome (HRS-AKI), characterized by marked impairment of kidney function due to haemodynamic changes that occur in late stages of liver cirrhosis. Besides, patients with cirrhosis also may develop chronic alterations of kidney function (chronic kidney disease, CKD), the incidence of which is increasing markedly and may be associated with clinical complications. The aim of this review is to provide the reader with an update of the most relevant aspects of alterations of kidney function in patients with cirrhossi that may be useful for theri clinical practice.

Critical care pharmacy service provision and workforce in adult extracorporeal membrane oxygenation centres: a multicentre cross-sectional survey

BACKGROUND

There is good evidence describing pharmacy workforce and service provision in general critical care units. However, no data exist from adult extracorporeal membrane oxygenation (ECMO) centres.

AIM

To describe workforce characteristics, pharmacy service provision, and pharmaceutical care activities in critical care units (CCUs) providing an adult ECMO service in the United Kingdom (UK) and compare to national staffing standards for CCUs.

METHOD

We conducted a multicentre, cross-sectional electronic survey inviting one pharmacy professional response per UK ECMO centre. We collated information on workforce, service provision, and pharmaceutical care activities provided by pharmacy teams in adult CCUs with an ECMO service.

RESULTS

The survey response rate was 90.9%: representatives of 10/11 tertiary hospitals providing ECMO services responded. Median critical care pharmacist to critical care bed was 1:12.1 (IQR: 1:9.4-1:14.9). Most centres (90.0%) did not meet national standards for pharmacy professionals to critical care bed staffing ratios for weekday services. Total critical care beds covered by the critical care pharmacy team varied across the UK: median (IQR) - 45 (37-80) beds. Two centres funded pharmacist time for ECMO activity, and one centre funded a pharmacy technician post. Median peak ECMO activity was 4 ECMO patients in a single day (IQR: 3-5). Most respondents reported reduced pharmacy service at weekends compared to weekday, with limited on-site support.

CONCLUSION

Most responding ECMO centres in the UK reported pharmacy staffing ratios below nationally agreed critical care standards. There was high variability in clinical pharmacy services to ECMO patients over 7 days.

Does initiating care in alternate care sites decrease time to disposition in the emergency department?

Objectives

During the coronavirus disease 2019 (COVID-19) pandemic surge, alternate care sites (ACS) such as the waiting room or hospital lobby were created amongst hospitals nationwide to help alleviate emergency department (ED) overflow. Despite the end of the pandemic surge, many of these ACS remain functional given the burden of prolonged ED wait times, with providers now utilizing the waiting room or ACS to initiate care. Therefore, the objective of this study is to evaluate if initiating patient care in ACS helps to decrease time to disposition.

Methods

Retrospective data were collected on 61,869 patient encounters presenting to an academic medical center ED. Patients with an emergency severity index (ESI) of 1 were excluded. The "pre-ACS" or control data consisted of 38,625 patient encounters from September 30, 2018 to October 1, 2019, prior to the development of ACS, in which the patient was seen by a physician after they were brought to an assigned ED room. The "post-ACS" study cohort consisted of 23,244 patient encounters from September 30, 2022 to October 1, 2023, after the initiation of ACS, during which patients were initially seen by a provider in an ACS. ACS at this institution included the three following areas: waiting room, ambulance waiting area, and a newly constructed ACS that was built next to the ED entrance on the first floor of the hospital. The newly constructed ACS consisted of 16 care spaces each containing an upright exam chair with dividers between each care space. Door-to-disposition time (DTD) was calculated by identifying the time when the patient entered the ED and the time when disposition was decided (admission requested or patient discharged). Using regression analysis, we compared the two data sets to determine significant differences among DTD time.

Results

The largest proportion of encounters were among ESI 3 patients, that is, 56.1%. There was a significant increase in median DTD for ESI 2 and 3 patients who were seen initially in an ACS compared to those who were not seen until they were in an assigned ER room. Specifically, there was a median increase of 40.9 min for ESI 2 patients and 18.8 min for ESI 3 patients who were seen initially in an ACS (p < 0.001). There was a 29-min decrease in median DTD for ESI 5 patients who were seen in ACS (p = 0.09).

Conclusions

Initiating patient care earlier in ACS did not appear to decrease DTD time for patients in the ED. Overall, the benefits of early initiation of care likely lie elsewhere within patient care and the ED throughput process.

A shift towards targeted post-ICU treatment: Multidisciplinary care for cardiac arrest survivors

Intensive Care Unit (ICU) survivorship comprises a burgeoning area of critical care medicine, largely due to our improved understanding of and concern for patients' recovery trajectory, and efforts to mitigate the post-acute complications of critical illness. Expansion of care beyond hospitalization is necessary, yet evidence for post-ICU clinics remains limited and mixed, as both interventions and target populations studied to date are too heterogenous to meaningfully demonstrate efficacy. Here, we briefly present the existing evidence and limitations related to post-ICU clinics, identify cardiac arrest survivors as a unique ICU subpopulation warranting further investigation and treatment, and propose a clinical framework that addresses the multifaceted needs of this well-defined patient population.

Development of a machine learning model for prediction of the duration of unassisted spontaneous breathing in patients during prolonged weaning from mechanical ventilation

PURPOSE

Treatment of patients undergoing prolonged weaning from mechanical ventilation includes repeated spontaneous breathing trials (SBTs) without respiratory support, whose duration must be balanced critically to prevent over- and underload of respiratory musculature. This study aimed to develop a machine learning model to predict the duration of unassisted spontaneous breathing.

MATERIALS AND METHODS

Structured clinical data of patients from a specialized weaning unit were used to develop (1) a classifier model to qualitatively predict an increase of duration, (2) a regressor model to quantitatively predict the precise duration of SBTs on the next day, and (3) the duration difference between the current and following day. 61 features, known to influence weaning, were included into a Histogram-based gradient boosting model. The models were trained and evaluated using separated data sets.

RESULTS

18.948 patient-days from 1018 individual patients were included. The classifier model yielded an ROC-AUC of 0.713. The regressor models displayed a mean absolute error of 2:50 h for prediction of absolute durations and 2:47 h for day-to-day difference.

CONCLUSIONS

The developed machine learning model showed informed results when predicting the spontaneous breathing capacity of a patient in prolonged weaning, however lacking prognostic quality required for direct translation to clinical use.

CCL14 testing to guide clinical practice in patients with AKI: Results from an international expert panel

PURPOSE

Urinary C-C motif chemokine ligand 14 (CCL14) is a strong predictor of persistent stage 3 acute kidney injury (AKI). Multiple clinical actions are recommended for AKI but how these are applied in individual patients and how the CCL14 test results may impact their application is unknown.

METHODS

We assembled an international panel of 12 experts and conducted a modified Delphi process to evaluate patients at risk for persistent stage 3 AKI (lasting 72 hours or longer). Using a Likert scale, we rated 11 clinical actions based on international guidelines applied to each case before and after CCL14 testing and analyzed the association between the strength and direction of recommendations and CCL14 results.

RESULTS

The strength and direction of clinical recommendations were strongly influenced by CCL14 results (P < 0.001 for the interaction). Nine (82%) recommendations for clinical actions were significantly impacted by CCL14 results (P < 0.001 comparing low to highest CCL14 risk category).

CONCLUSIONS

Most recommendations for care of patients with stage 2-3 by an international panel of experts were strongly modified by CCL14 test results. This work should set the stage for clinical practice protocols and studies to determine the effects of recommended actions informed by CCL14.

Near-miss and maternal sepsis mortality: A qualitative study of survivors and support persons

BACKGROUND

Prior studies have shown that maternal deaths due to sepsis occur due to delays in recognition, treatment, and escalation of care through medical chart reviews. This study was conducted to obtain the patient perspective for near-miss and maternal mortality cases due to sepsis.

OBJECTIVE

To identify quality improvement opportunities for improving maternal sepsis through patient and support person experiences.

STUDY DESIGN

Twenty semi-structured interviews and three follow-up focus groups with patients who experienced critical illness from maternal sepsis in the United States and their support persons (when available) were conducted from May 23, 2022, through October 14, 2022. In this qualitative study, data were analyzed using inductive thematic analysis.

RESULTS

In this qualitative study of patients with maternal sepsis and their support persons, four main quality improvement themes were identified. The themes were the following: (1) participants reported a lack of awareness of pregnancy-related warning signs and symptoms of when to seek care, (2) many of the presenting symptoms participants experienced were not typical of expected warning signs of maternal sepsis, such as severe pain, overwhelming tiredness, and lack of fever (3) participant concerns were met with dismissal leading to delays in diagnosis, (4) participants experienced long-term sequelae but had difficulty receiving screening and referrals for treatment.

CONCLUSIONS

The findings of this study suggest that standardized patient education about the warning signs of maternal sepsis and provider education about the presentation of maternal sepsis, improved listening to patients, and follow-up for sequalae of sepsis are needed.

The enteroendocrine axis and its effect on gastrointestinal function, nutrition, and inflammation

PURPOSE OF REVIEW

Gastrointestinal (GI) dysfunction limits enteral nutrition (EN) delivery in critical illness and contributes to systemic inflammation. The enteroendocrine (EE) axis plays an integral role in this interface between nutrition, inflammation, and GI function in critical illness. In this review, we present an overview of the EE system with a focus on its role in GI inflammation and function.

RECENT FINDINGS

Enteroendocrine cells have been primarily described in their role in macronutrient digestion and absorption. Recent research has expanded on the diverse functions of EE cells including their ability to sense microbial peptides and metabolites and regulate immune function and inflammation. Therefore, EE cells may be both affected by and contribute to many pathophysiologic states and interventions of critical illness such as dysbiosis , inflammation, and alternative EN strategies. In this review, we present an overview of EE cells including their growing role in nonnutrient functions and integrate this understanding into relevant aspects of critical illness with a focus on EN.

SUMMARY

The EE system is key in maintaining GI homeostasis in critical illness, and how it is impacted and contributes to outcomes in the setting of dysbiosis , inflammation and different feeding strategies in critical illness should be considered.

Severe amlodipine toxicity: A medical dilemma managed with therapeutic plasma exchange

Amlodipine poisoning is a nightmare for treating clinicians because of the intractable hypotension and bradycardia induced by the drug, which requires a balanced treatment algorithm. We encountered a case of severe Amlodipine toxicity (450 mg) who presented with complaints of nausea, multiple episodes of vomiting, and chest discomfort. On arrival at the EMD, the patient had significant hypotension (80/46 mmHg), bradycardia (40 beats/min), and a fall in oxygen saturation (75 %). He was symptomatically managed with inotropes, IV calcium, IV fluids, and oxygen supplementation. We decided to go forward with Therapeutic Plasma Exchange (TPE) in an attempt to remove the inciting agent. Two sessions of TPE were performed and the patient showed significant improvement post-procedure which led to the discharge of the patient within 10 days of admission. This case report highlights the noteworthiness of TPE in treating significantly high doses of drug poisoning.

Outpatient glucocorticoid use and COVID-19 outcomes: a population-based study

INTRODUCTION

Owing to controversy information surrounds effect of glucocorticoids on the evolution of COVID-19, we evaluate the effects of outpatient glucocorticoid use on the severity and progression of COVID-19 and risk of infection and analyse the effect of window of exposure and dose.

METHODS

We conducted a population-based case - control study, involving 4 substudies: (i) Hospitalisation; (ii) Mortality, using subjects hospitalised with a PCR + as cases and subjects without a PCR + as controls; (iii) Progression, including subjects with a PCR + (hospitalised versus non-hospitalised); and (iv) Susceptibility, with all subjects with a PCR + and subjects without a PCR + . Adjusted odds ratios (ORa) and their 95% confidence intervals (95% CI) were calculated.

RESULTS

The outpatient glucocorticoid use was associated with an increased risk of hospitalisation (aOR 1.79; 95% CI 1.56-2.05), mortality (aOR 2.30; 95% CI 1.68-3.15), progression (aOR 1.69; 95% CI 1.43-2.00) and susceptibility (aOR 1.29, 95% CI 1.19-1.41). Furthermore, the effects was observed to be greater at higher doses and the closer that drug use approached the outcome date, with an almost fourfold increase in mortality among users in the previous month (aOR 3.85; 95% CI 2.63-5.62).

CONCLUSIONS

According to the results of this real-world data study, outpatient glucocorticoid use should be considered in making decisions about intrahospital treatment.

Clinical characteristics and outcomes of COVID-19 cases admitted to adult intensive care units during the pandemic: A single center experience

BACKGROUND

COVID-19 is the largest recorded pandemic in history. It causes several complications such as shock, pneumonia, acute respiratory distress syndrome, and organ failure. The objective was to determine COVID-19 outcomes and risk factors in the intensive care (ICU) setting.

METHODS

A retrospective review of prospectively collected data was conducted. Adult patients with a positive RT-PCR test for COVID-19 admitted to ICUs of a tertiary care hospital between 2020 and 2022 were included. Patients who had severe complex trauma were excluded. The outcomes examined included ventilation use and duration, length of stay (LOS), and mortality.

RESULTS

A total of 964 patients were included. The mean ( ± standard deviation, SD) age was 63.7 ± 16.9 years. The majority of the patients were males (59.0 %) and Saudi (75.7 %). Ventilation use was documented in 443 (57.1 %) patients, with a mean ( ± SD) ventilation duration of 9.7 ± 8.4 days. Death occurred in 361 (37.4 %) patients after a mean ( ± SD) of 33.3 ± 44.5 days from infection. The mean ( ± SD) LOS was 30.6 ± 54.1 days in hospital and 5.2 ± 5.4 days in ICU. Ventilation use was associated with older age, males, longer ICU LOS, mortality, and admission to medical-surgical ICU. Crude mortality use was associated with older age, longer ICU LOS, use of ventilator, shorter ventilation duration, and admission to medical-surgical or respiratory ICUs.

CONCLUSIONS

COVID-19 patients admitted to adult ICUs are at high risk of death and mechanical ventilation. The crude risks of both outcomes are higher in older age and longer ICU LOS and are very variable by ICU type.

TEMPORAL CHANGES IN INNATE AND ADAPTIVE IMMUNITY DURING SEPSIS AS DETERMINED BY ELISPOT

ABSTRACT

Background: The inability to evaluate host immunity in a rapid quantitative manner in patients with sepsis has severely hampered development of novel immune therapies. The enzyme-linked immunospot (ELISpot) assay is a functional bioassay that measures the number of cytokine-secreting cells and the relative amount of cytokine produced at the single-cell level. A key advantage of ELISpot is its excellent dynamic range enabling a more precise quantifiable assessment of host immunity. Herein, we tested the hypothesis that the ELISpot assay can detect dynamic changes in both innate and adaptive immunity as they often occur during sepsis. We also tested whether ELISpot could detect the effect of immune drug therapies to modulate innate and adaptive immunity. Methods: Mice were made septic using sublethal cecal ligation and puncture. Blood and spleens were harvested serially, and ex vivo interferon γ and TNF-α production were compared by ELISpot and enzyme-linked immunosorbent assay. The capability of ELISpot to detect changes in innate and adaptive immunity due to in vivo immune therapy with dexamethasone, IL-7, and arginine was also evaluated. Results: ELISpot confirmed a decreased innate and adaptive immunity responsiveness during sepsis progression. More importantly, ELISpot was also able to detect changes in adaptive and innate immunity in response to immune-modulatory reagents, for example, dexamethasone, arginine, and IL-7, in a readily quantifiable manner, as predicted by the reagents known mechanisms of action. ELISpot and enzyme-linked immunosorbent assay results tended to parallel one another although some differences were noted. Conclusion: ELISpot offers a unique capability to assess the functional status of both adaptive and innate immunity over time. The results presented herein demonstrate that ELISpot can also be used to detect and follow the in vivo effects of drugs to ameliorate sepsis-induced immune dysfunction. This capability would be a major advance in guiding new immune therapies in sepsis.

Implementing debriefing after cardiac arrest: benefits and challenges

Healthcare professionals, including nurses, will be involved in the care and management of patients in cardiac arrest. This highly stressful and demanding situation can lead to breakdowns in communication, difficulty in decision-making and emotional distress for members of the healthcare team. Debriefing is a recommended tool that team members can use to acknowledge what went well, what could be improved and areas for learning or development. However, debriefing is often not prioritised due to pressures in clinical practice. This article discusses the benefits of debriefing and outlines some of the approaches and tools that may be used. The author argues that by recognising the importance of debriefing after cardiac arrests in the hospital setting and committing to best practices, nurses can be better prepared for the challenges of resuscitation and improve patient outcomes.

Ventilator-associated pneumonia: pathobiological heterogeneity and diagnostic challenges

Ventilator-associated pneumonia (VAP) affects up to 20% of critically ill patients and induces significant antibiotic prescription pressure, accounting for half of all antibiotic use in the ICU. VAP significantly increases hospital length of stay and healthcare costs yet is also associated with long-term morbidity and mortality. The diagnosis of VAP continues to present challenges and pitfalls for the currently available clinical, radiological and microbiological diagnostic armamentarium. Biomarkers and artificial intelligence offer an innovative potential direction for ongoing future research. In this Review, we summarise the pathobiological heterogeneity and diagnostic challenges associated with VAP.

Association of coinfections with differences in outcomes across COVID-19 variants

Background

In previous studies, there was an increase in mortality with secondary coinfections in all COVID-19 variants. However, no prior study has explored the association of coinfection with outcomes of hospitalized patients among the COVID-19 variants (Alpha, Delta, and Omicron).

Methods

This observational cohort study involved 21,186 patients hospitalized with COVID-19 in 25 hospitals in Texas. Patients were divided into groups by surges of COVID-19: Alpha (November 1, 2020-February 10, 2021), Delta (July 10, 2021-October 14, 2021), and Omicron (December 21, 2021-March 3, 2022). Data were collected from electronic health records using methodology from the Viral Respiratory Illness Universal Study COVID-19 registry (NCT04323787) of COVID-19 hospitalizations. Multivariable Cox-proportional hazard regression model assessed the adjusted effect of different surge periods on mortality.

Results

Bacterial coinfections varied among hospitalization surges associated with Alpha (8.5%), Delta (11.7%), and Omicron (11.9%) variants. Adjusted analyses showed a higher 30-day and 90-day mortality in all variants when coinfections were present compared with isolated COVID-19 infection. In particular, 30-day and 90-day mortality were significantly worse with Delta compared to Alpha and Omicron.

Conclusions

All variants were associated with a higher mortality when bacterial coinfections were present. Delta was associated with a higher risk-adjusted mortality at 30 days and thereafter.

Preliminary Observations of the Loke Microdialysis in an Experimental Pig Model: Are We Ready for Continuous Monitoring of Brain Energy Metabolism?

BACKGROUND

Brain energy metabolism is often disturbed after acute brain injuries. Current neuromonitoring methods with cerebral microdialysis (CMD) are based on intermittent measurements (1-4 times/h), but such a low frequency could miss transient but important events. The solution may be the recently developed Loke microdialysis (MD), which provides high-frequency data of glucose and lactate. Before clinical implementation, the reliability and stability of Loke remain to be determined in vivo. The purpose of this study was to validate Loke MD in relation to the standard intermittent CMD method.

METHODS

Four pigs aged 2-3 months were included. They received two adjacent CMD catheters, one for standard intermittent assessments and one for continuous (Loke MD) assessments of glucose and lactate. The standard CMD was measured every 15 min. Continuous Loke MD was sampled every 2-3 s and was averaged over corresponding 15-min intervals for the statistical comparisons with standard CMD. Intravenous glucose injections and intracranial hypertension by inflation of an intracranial epidural balloon were performed to induce variations in intracranial pressure, cerebral perfusion pressure, and systemic and cerebral glucose and lactate levels.

RESULTS

In a linear mixed-effect model of standard CMD glucose (mM), there was a fixed effect value (± standard error [SE]) at 0.94 ± 0.07 (p < 0.001) for Loke MD glucose (mM), with an intercept at - 0.19 ± 0.15 (p = 0.20). The model showed a conditional R2 at 0.81 and a marginal R2 at 0.72. In a linear mixed-effect model of standard CMD lactate (mM), there was a fixed effect value (± SE) at 0.41 ± 0.16 (p = 0.01) for Loke MD lactate (mM), with an intercept at 0.33 ± 0.21 (p = 0.25). The model showed a conditional R2 at 0.47 and marginal R2 at 0.17.

CONCLUSIONS

The established standard CMD glucose thresholds may be used as for Loke MD with some caution, but this should be avoided for lactate.

Alarm fatigue and sleep quality in medical staff-a Polish-Czech-Slovak study on workplace ergonomics

Background

Alarms are crucial in informing Healthcare Workers (HCWs) about critical patient needs, but unmanaged frequency and noise of alarms can de-sensitize medical staff and compromise patient safety. Alarm fatigue is identified as the major cause of the clinical alarm management problem. It occurs when the medical staff is overwhelmed by the number of clinical alarms.

Methods

The survey was conducted online using Google's form-making tools from June to July 2023. There were three parts to the survey used in the study: a socio-demographic metric, the Alarm Fatigue Assessment Questionnaire (AFAQ), and The Pittsburgh Sleep Quality Index (PSQI). A significance level of 0.05 was used in the analysis.

Results

The survey included 756 medical professionals from three European countries (Slovakia, the Czech Republic and Poland). The participants in the study were 42 years old on average, and they had 12 years of work experience. 603 out of 756 survey participants had poor sleep quality, 147 had good sleep quality, and 6 did not provide an answer. This study analyzed the alarm fatigue levels of respondents in every country. In the Czech Republic, Poland and Slovakia, a statistically significant association (p = 0.039, p = 0.001, p < 0.001) was found between alarm fatigue and sleep quality in medical staff.

Conclusion

Based on our study, alarm fatigue and sleep quality of HCWs are correlated. Therefore, alarm fatigue and sleep hygiene should be monitored.

Effectiveness of nurse-led non-pharmacological interventions on outcomes of delirium in adults: A meta-analysis of randomized controlled trials

BACKGROUND

Delirium is a common complication among adults. It is essential to improve the outcomes of delirium.

AIM

To systematically synthesize the evidence on the effectiveness of the nurse-led non-pharmacological interventions on outcomes of delirium in adults.

METHODS

Electronic databases including CINAHL, Cochrane Library, MEDLINE, EMBASE, PubMed, Web of Science, PsycINFO, and Clinical Trial Registration were searched comprehensively by the authors. The authors reviewed the full text and assessed the risk of bias using the Cochrane Risk of Bias Tool 2.0. The meta-analysis was performed using RevMan and Stata software. The forest plots showed the overall effect of the included study and the I2 test was used to assess the degree of heterogeneity between studies. Random effects models were used to analyze studies with significant heterogeneity.

RESULTS

A total of 32 studies (10,122 participants) were included in the meta-analysis. Nurse-led non-pharmacological interventions resulted in a significantly lower incidence of delirium compared with the usual care/control group (risk ratio = 0.74, p < .001) and reduced mortality in the hospital compared with usual care (risk ratio = 0.81, p = .04). However, the implementation of nurse-led, non-pharmacological interventions had no significant effect on the duration, severity of delirium, or length of hospital stay.

LINKING EVIDENCE TO ACTION

Our findings suggest that the nurse-led, non-pharmacological strategy was effective in reducing the incidence of delirium and mortality in the hospital. Multicomponent interventions were the most effective strategy for reducing the incidence of delirium in adults.

Epidemiology of Diffuse Alveolar Hemorrhage in Pediatric Allogeneic Hematopoietic Cell Transplantation Recipients

Diffuse alveolar hemorrhage (DAH) is a life-threatening pulmonary toxicity that can arise after hematopoietic cell transplantation (HCT). Risk factors and outcomes are not well understood owing to a sparsity of cases spread across multiple centers. The objectives of this epidemiologic study were to characterize the incidence, outcomes, transplantation-related risk factors and comorbid critical care diagnoses associated with post-HCT DAH. Retrospective analysis was performed in a multicenter cohort of 6995 patients age ≤21 years who underwent allogeneic HCT between 2008 and 2014 identified through the Center for International Blood and Marrow Transplant Research registry and cross-matched with the Virtual Pediatric Systems database to obtain critical care characteristics. A multivariable Cox proportional hazard model was used to determine risk factors for DAH. Logistic regression models were used to determine critical care diagnoses associated with DAH. Survival outcomes were analyzed using both a landmark approach and Cox regression, with DAH as a time-varying covariate. DAH occurred in 81 patients at a median of 54 days post-HCT (interquartile range, 23 to 160 days), with a 1-year post-transplantation cumulative incidence probability of 1.0% (95% confidence interval [CI], .81% to 1.3%) and was noted in 7.6% of all pediatric intensive care unit patients. Risk factors included receipt of transplantation for nonmalignant hematologic disease (reference: malignant hematologic disease; hazard ratio [HR], 1.98; 95% CI, 1.22 to 3.22; P = .006), use of a calcineurin inhibitor (CNI) plus mycophenolate mofetil (MMF) as graft-versus-host disease (GVHD) prophylaxis (referent: CNI plus methotrexate; HR, 1.89; 95% CI, 1.07 to 3.34; P = .029), and grade III-IV acute GVHD (HR, 2.67; 95% CI, 1.53-4.66; P < .001). Critical care admitted patients with DAH had significantly higher rates of systemic hypertension, pulmonary hypertension, pericardial disease, renal failure, and bacterial/viral/fungal infections (P < .05) than those without DAH. From the time of DAH, median survival was 2.2 months, and 1-year overall survival was 26% (95% CI, 17% to 36%). Among all HCT recipients, the development of DAH when considered was associated with a 7-fold increase in unadjusted all-cause post-HCT mortality (HR, 6.96; 95% CI, 5.42 to 8.94; P < .001). In a landmark analysis of patients alive at 2 months post-HCT, patients who developed DAH had a 1-year overall survival of 33% (95% CI, 18% to 49%), compared to 82% (95% CI, 81% to 83%) for patients without DAH (P < .001). Although DAH is rare, it is associated with high mortality in the post-HCT setting. Our data suggest that clinicians should have a heightened index of suspicion of DAH in patients with pulmonary symptoms in the context of nonmalignant hematologic indication for HCT, use of CNI + MMF as GVHD prophylaxis, and severe acute GVHD. Further investigations and validation of modifiable risk factors are warranted given poor outcomes.

Association of extreme hyperoxemic events and mortality in pediatric critical care: an observational cohort study

Objective

Our aim was to confirm whether extreme hyperoxemic events had been associated with excess mortality in our diverse critical care population.

Methods

Retrospective analysis of 9 years of data collected in the pediatric and cardiothoracic ICUs in Children's Hospital Los Angeles was performed. The analysis was limited to those mechanically ventilated for at least 24 h, with at least 1 arterial blood gas measurement. An extreme hyperoxemic event was defined as a PaO2 of ≥300 torr. Multivariable logistic regression was used to assess the association of extreme hyperoxemia events and mortality, adjusting for confounding variables. Selected a-priori, these were Pediatric Risk of Mortality III predicted mortality, general or cardiothoracic ICU, number of blood gas measurements, as well as an abnormal blood gas measurements (pH < 7.25, pH > 7.45, and PaO2 < 50 torr).

Results

There were 4,003 admissions included with a predicted mortality of 7.1% and an actual mortality of 9.7%. Their care was associated with 75,129 blood gas measurements, in which abnormal measurements were common. With adjustments for these covariates, any hyperoxemic event was associated with excess mortality (p < 0.001). Excess mortality increased with multiple hyperoxemic events (p < 0.046). Additionally, treatment resulting in SpO2 > 98% markedly increased the risk of a hyperoxemic event.

Conclusion

Retrospective analysis of critical care admissions showed that extreme hyperoxemic events were associated with higher mortality. Supplemental oxygen levels resulting in SpO2 > 98% should be avoided.

Effect of automated versus conventional ventilation on mechanical power of ventilation-A randomized crossover clinical trial

INTRODUCTION

Mechanical power of ventilation, a summary parameter reflecting the energy transferred from the ventilator to the respiratory system, has associations with outcomes. INTELLiVENT-Adaptive Support Ventilation is an automated ventilation mode that changes ventilator settings according to algorithms that target a low work-and force of breathing. The study aims to compare mechanical power between automated ventilation by means of INTELLiVENT-Adaptive Support Ventilation and conventional ventilation in critically ill patients.

MATERIALS AND METHODS

International, multicenter, randomized crossover clinical trial in patients that were expected to need invasive ventilation > 24 hours. Patients were randomly assigned to start with a 3-hour period of automated ventilation or conventional ventilation after which the alternate ventilation mode was selected. The primary outcome was mechanical power in passive and active patients; secondary outcomes included key ventilator settings and ventilatory parameters that affect mechanical power.

RESULTS

A total of 96 patients were randomized. Median mechanical power was not different between automated and conventional ventilation (15.8 [11.5-21.0] versus 16.1 [10.9-22.6] J/min; mean difference -0.44 (95%-CI -1.17 to 0.29) J/min; P = 0.24). Subgroup analyses showed that mechanical power was lower with automated ventilation in passive patients, 16.9 [12.5-22.1] versus 19.0 [14.1-25.0] J/min; mean difference -1.76 (95%-CI -2.47 to -10.34J/min; P < 0.01), and not in active patients (14.6 [11.0-20.3] vs 14.1 [10.1-21.3] J/min; mean difference 0.81 (95%-CI -2.13 to 0.49) J/min; P = 0.23).

CONCLUSIONS

In this cohort of unselected critically ill invasively ventilated patients, automated ventilation by means of INTELLiVENT-Adaptive Support Ventilation did not reduce mechanical power. A reduction in mechanical power was only seen in passive patients.

STUDY REGISTRATION

Clinicaltrials.gov (study identifier NCT04827927), April 1, 2021.

URL OF TRIAL REGISTRY RECORD

https://clinicaltrials.gov/study/NCT04827927?term=intellipower&rank=1.

Association of immune deficiency with prognosis and corticosteroid treatment benefits among patients with acute respiratory distress syndrome

Background

The role of corticosteroids in acute respiratory distress syndrome (ARDS) remains contentious. This study aims to investigate the prognostic significance of immune deficiency in patients with ARDS and its response to varying doses of corticosteroids.

Methods

This single-center, retrospective cohort study enrolled 657 ARDS patients from January 24, 2008, to September 12, 2022, at Zhongshan Hospital of Fudan University, Shanghai, China. The patients were categorized into a discovery dataset (n=357) and a validation dataset (n=300), based on admission date. Further validation of the results in the validation dataset was used to enhance the credibility of the study conclusions. The study examined the association between immune deficiency and the patients' clinical characteristics, treatment measures, and prognosis. The primary outcome was 28-day mortality post disease onset. Data analysis was conducted from June 15, 2023 to August 15, 2023.

Results

The initial risk factor analysis in the discovery dataset was primarily based on the clinical characteristics, and the results suggested that immune deficiency likely impacted overall survival among patients receiving different doses of corticosteroid treatment. Multivariate analysis identified immune deficiency as an independent prognostic factor for overall survival in both the discovery and validation datasets. The final analysis revealed that patients with mild to moderate ARDS [discovery dataset: hazard ratio (HR) =1.719; 95% confidence interval (CI): 1.229-2.406; log-rank test P=0.001; validation dataset: HR =1.874; 95% CI: 1.238-2.837; log-rank test P=0.002] or severe ARDS (discovery dataset: HR =1.874; 95% CI: 1.007-3.488; log-rank test P=0.04; validation dataset: HR =1.698; 95% CI: 1.042-2.768; log-rank test P=0.03) with immune deficiency exhibited lower overall survival rates. Patients with mild to moderate ARDS and immune deficiency showed greater benefits from low-dose corticosteroid treatment (HR =0.409; 95% CI: 0.249-0.671; P<0.001 for interaction), whereas those with severe ARDS and immune deficiency benefitted from both low and high-dose treatments (low corticosteroid: HR =0.299; 95% CI: 0.136-0.654; high corticosteroid: HR =0.458; 95% CI: 0.214-0.981; P=0.005 for interaction).

Conclusions

Immune deficiency is an independent risk factor in ARDS. Incorporating it into the disease severity grading system based on the Berlin criteria may enhance personalized treatment approaches for ARDS patients. These findings warrant further validation through prospective, large-scale, multicenter randomized controlled trials (RCTs).

Predicting Tracheostomy Need on Admission to the Intensive Care Unit-A Multicenter Machine Learning Analysis

OBJECTIVE

It is difficult to predict which mechanically ventilated patients will ultimately require a tracheostomy which further predisposes them to unnecessary spontaneous breathing trials, additional time on the ventilator, increased costs, and further ventilation-related complications such as subglottic stenosis. In this study, we aimed to develop a machine learning tool to predict which patients need a tracheostomy at the onset of admission to the intensive care unit (ICU).

STUDY DESIGN

Retrospective Cohort Study.

SETTING

Multicenter Study of 335 Intensive Care Units between 2014 and 2015.

METHODS

The eICU Collaborative Research Database (eICU-CRD) was utilized to obtain the patient cohort. Inclusion criteria included: (1) Age >18 years and (2) ICU admission requiring mechanical ventilation. The primary outcome of interest included tracheostomy assessed via a binary classification model. Models included logistic regression (LR), random forest (RF), and Extreme Gradient Boosting (XGBoost).

RESULTS

Of 38,508 invasively mechanically ventilated patients, 1605 patients underwent a tracheostomy. The XGBoost, RF, and LR models had fair performances at an AUROC 0.794, 0.780, and 0.775 respectively. Limiting the XGBoost model to 20 features out of 331, a minimal reduction in performance was observed with an AUROC of 0.778. Using Shapley Additive Explanations, the top features were an admission diagnosis of pneumonia or sepsis and comorbidity of chronic respiratory failure.

CONCLUSIONS

Our machine learning model accurately predicts the probability that a patient will eventually require a tracheostomy upon ICU admission, and upon prospective validation, we have the potential to institute earlier interventions and reduce the complications of prolonged ventilation.

Effectiveness of a delirium risk assessment and multidisciplinary care approach in reducing delirium incidence among surgical intensive care unit patients: A retrospective pre-post intervention study

BACKGROUND

Delirium is a common complication in intensive care unit (ICU) patients. It can lead to various adverse events. In this study, we investigated the effectiveness of combining the use of the PREdiction of DELIRium (PRE-DELIRIC) model for delirium risk assessment and the use of a multicomponent care bundle for delirium assessment, prevention, and care in terms of reductions in the incidence of delirium among surgical ICU patients.

METHODS

This retrospective study included surgical ICU patients who had received PRE-DELIRIC-guided SMART/SmART care (SMART care: SmART bundle plus multidisciplinary team; SmART care: Sleep/sweet sense of home (creating a comforting and restful environment for patients), Assessment (regular and thorough evaluation of patient needs and conditions), Release (revised endotracheal tube care/removal, restraint device care, and immobility reduction for patient comfort), and Time (reorientation of time to optimize patient care schedules) in our hospital between May 2022 and March 2023 (intervention group) and individuals who had received usual care between January 2021 and April 2022 (historical control group). The SmART intervention involves providing care in the following domains: sleep/sweet sense of home, assessment, release, and time. Patients with a PRE-DELIRIC score of >30% received SMART care, which includes multidisciplinary (physicians, pharmacists, respiratory therapists, and physiotherapists) care in addition to SmART care. For the control group, usual care was provided following the guidelines for the prevention and management of pain, agitation, delirium, immobility, and sleep disruption. The primary outcome was delirium incidence during ICU stay, which was assessed using the Intensive Care Delirium Screening Checklist. The secondary outcomes were the duration of ICU stay, rate of unplanned self-extubation, and status of ICU discharge.

RESULTS

The intervention and control groups comprised 184 and 197 patients, respectively; their mean ages were 63.7 ± 18.4 years and 62.4 ± 19.5 years, respectively. The incidence of delirium was significantly lower (p = 0.001) in the intervention group (22.3%) than in the control group (47.7%).

CONCLUSION

Our findings suggest that the PRE-DELIRIC-guided SMART/SmART care intervention is effective in preventing and managing delirium among surgical ICU patients.

Tinnitus after COVID-19 vaccination: Findings from the vaccine adverse event reporting system and the vaccine safety datalink

PURPOSE

To assess the occurrence of tinnitus following COVID-19 vaccination using data mining and descriptive analyses in two U.S. vaccine safety surveillance systems.

METHODS

Reports of tinnitus after COVID-19 vaccination to the Vaccine Adverse Event Reporting System (VAERS) from 2020 through 2024 were examined using empirical Bayesian data mining and by calculating reporting rates. In the Vaccine Safety Datalink (VSD) population, ICD-10 coded post-vaccination medical visits were examined using tree-based data mining, and tinnitus visit incidence rates during post-vaccination days 1-140 were calculated by age group for COVID-19 vaccines and for comparison, influenza vaccine.

RESULTS

VAERS data mining did not find disproportionate reporting of tinnitus for any COVID-19 vaccine. VAERS received up to 84.82 tinnitus reports per million COVID-19 vaccine doses administered. VSD tree-based data mining found no signals for tinnitus. VSD tinnitus visit incidence rates after COVID-19 vaccines were similar to those after influenza vaccine except for the group aged ≥65 years (Moderna COVID-19 vaccine, 165 per 10,000 person-years; Pfizer-BioNTech COVID-19 vaccine, 154; influenza vaccine, 135).

CONCLUSIONS

Overall, these findings do not support an increased risk of tinnitus following COVID-19 vaccination but cannot definitively exclude the possibility. Descriptive comparisons between COVID-19 and influenza vaccines were limited by lack of adjustment for potential confounding factors.

Bloodstream infections among patients receiving therapeutic plasma exchanges in the intensive care unit: a 10 year multicentric study

BACKGROUND

Therapeutic plasma exchanges (TPE), which affect the humoral response, are often performed in combination with immunosuppressive drugs. For this reason, TPE may be associated with an increased susceptibility to infections. We aimed to describe blood stream infection (BSI) incidence in ICU patients treated with TPE and to identify associated risk factors.

METHODS

We retrospectively included patients that had received at least one session of TPE in the ICU of one of the 4 participating centers (all in Paris, France) between January 1st 2010 and December 31th 2019. Patients presenting with a BSI during ICU stay were compared to patients without such an infection. Risk factors for BSI were identified by a multivariate logistic regression model.

RESULTS

Over 10 years in the 4 ICUs, 387 patients were included, with a median of 5 [2-7] TPE sessions per patient. Most frequent indications for TPE were thrombotic microangiopathy (47%), central nervous system inflammatory disorders (11%), hyperviscosity syndrome (11%) and ANCA associated vasculitis (8.5%). Thirty-one patients (8%) presented with a BSI during their ICU stay, a median of 7 [3-11] days after start of TPE. In a multivariate logistic regression model, diabetes (OR 3.32 [1.21-8.32]) and total number of TPE sessions (OR 1.14 [1.08-1.20]) were independent risk factors for BSI. There was no difference between TPE catheter infection related BSI (n = 11 (35%)) and other sources of BSI (n = 20 (65%)) regarding catheter insertion site (p = 0.458) or rate of TPE catheter related deep vein thrombosis (p = 0.601). ICU course was severe in patients presenting with BSI when compared to patients without BSI, with higher need for mechanical ventilation (45% vs 18%, p = 0.001), renal replacement therapy (42% vs 20%, p = 0.011), vasopressors (32% vs 12%, p = 0.004) and a higher mortality (19% vs 5%, p = 0.010).

CONCLUSION

Blood stream infections are frequent in patients receiving TPE in the ICU, and are associated with a severe ICU course. Vigilant monitoring is crucial particularly for patients receiving a high number of TPE sessions.

Role of artificial intelligence in critical care nutrition support and research

Nutrition plays a key role in the comprehensive care of critically ill patients. Determining optimal nutrition strategy, however, remains a subject of intense debate. Artificial intelligence (AI) applications are becoming increasingly common in medicine, and specifically in critical care, driven by the data-rich environment of intensive care units. In this review, we will examine the evidence regarding the application of AI in critical care nutrition. As of now, the use of AI in critical care nutrition is relatively limited, with its primary emphasis on malnutrition screening and tolerance of enteral nutrition. Despite the current scarcity of evidence, the potential for AI for more personalized nutrition management for critically ill patients is substantial. This stems from the ability of AI to integrate multiple data streams reflecting patients' changing needs while addressing inherent heterogeneity. The application of AI in critical care nutrition holds promise for optimizing patient outcomes through tailored and adaptive nutrition interventions. A successful implementation of AI, however, necessitates a multidisciplinary approach, coupled with careful consideration of challenges related to data management, financial aspects, and patient privacy.

Multicenter Retrospective Review of Ketamine Use in Pediatric Intensive Care Units (Ketamine-PICU Study)

Objective

Describe continuous infusion (CI) ketamine practices in pediatric intensive care units (PICUs) and evaluate its effect on pain/sedation scores, exposure to analgesics/sedatives, and adverse effects (AEs).

Methods

Multicenter, retrospective, observational study in children <18 years who received CI ketamine between 2014 and 2017. Time spent in goal pain/sedation score range and daily cumulative doses of analgesics/sedatives were compared from the 24 hours (H) prior to CI ketamine to the first 24H and 25-48H of the CI. Adverse effects were collected over the first 7 days of CI ketamine.

Results

Twenty-four patients from 4 PICUs were included; median (IQR) age 7 (1-13.25) years, 54% female (n = 13), 92% intubated (n = 22), 25% on CI vasopressors (n = 6), and 33% on CI paralytics (n = 8). Ketamine indications were analgesia/sedation (n = 21, 87.5%) and status epilepticus (n = 3, 12.5%). Median starting dose was 0.5 (0.48-0.70) mg/kg/hr and continued for a median of 2.4 (1.3-4.4) days. There was a significant difference in mean proportion of time spent within goal pain score range (24H prior: 74% ± 14%, 0-24H: 85% ± 10%, and 25-48H: 72% ± 20%; p=0.014). A significant reduction in median morphine milligram equivalents (MME) was seen (24H prior: 58 (8-195) mg vs. 0-24H: 4 (0-69) mg and p=0.01), but this was not sustained (25-48H: 24 (2-246) mg and p=0.29). Common AEs were tachycardia (63%), hypotension (54%), secretions/suctioning (29%), and emergence reactions (13%).

Conclusions

Ketamine CI improved time in goal pain score range and significantly reduced MME, but this was not sustained. Larger prospective studies are needed in the pediatric population.

Evaluating the effectiveness of a sliding window technique in machine learning models for mortality prediction in ICU cardiac arrest patients

Extensive research has been devoted to predicting ICU mortality, to assist clinical teams managing critical patients. Electronic health records (EHR) contain both static and dynamic medical data, with the latter accumulating during ICU stays. Existing models often rely on a fixed time window (e.g., first 24 h) for prediction, potentially missing vital post-24-hour data. The present study aims to improve mortality prediction for ICU patients following Cardiac Arrest (CA) using a dynamic sliding window approach that accommodates evolving data characteristics. Our cohort included 2331 CA patients, of whom 684 died in the ICU and 1647 survived. Applying the sliding window technique, we created six different time windows and used each separately for model training and validation. We compared our results to a baseline accumulative window. The different time windows created by the sliding window technique differed in their prediction performance and outperformed the baseline 24-hour window significantly. The XGBoost model outperformed all other models, with the 30-42 h time window achieving the best results (AUC = 0.8, accuracy = 0.77). Our work shows that the sliding window technique is effective in improving mortality prediction. We demonstrated how important time-window selection is and showed that enhancing it can save time and thus improve mortality prediction. These findings promise to improve the clinical team's efficiency in prioritizing patients and giving greater attention to higher-risk patients. To conclude, mortality prediction in the ICU can be improved if we consider alternative time windows instead of the 24-hour window, which is currently the most widely accepted among scoring systems today.

Bronchopleural fistula management in a pediatric patient requiring extracorporeal membrane oxygenation

Bronchopleural fistula (BPF) is a connection between the bronchus and pleural cavity. It is associated with high morbidity and mortality and management of BPF has not been well described in the pediatric population. We describe a 2-year-old girl who presented with fever and increased work of breathing, found to have atypical hemolytic uremic syndrome and Streptococcus necrotizing pneumonia with development of persistent air leak due to bronchopleural fistulas requiring extracorporeal membrane oxygenation (ECMO). Three endobronchial valves were placed with successful resolution of bronchopleural fistulas. She required tracheostomy for chronic respiratory failure and endobronchial valves were eventually removed. Approximately 3.5 months after discharge to acute care rehabilitation, tracheostomy was successfully decannulated. This case highlights the successful use of endobronchial valves for resolution of BPF while on ECMO as well as the importance of further studies on optimal candidates, timing and duration of intervention in addition to sequelae of endobronchial valve placement.

A safety evaluation of intermittent high-dose inhaled nitric oxide in viral pneumonia due to COVID-19: a randomised clinical study

High-dose inhaled Nitric Oxide (iNO) has been shown to have anti-inflammatory, vasodilator, and antimicrobial properties, resulting in improved arterial oxygenation as well as a beneficial therapeutic effect on lower respiratory tract infections. This study evaluated the safety and efficacy of 150-ppm intermittent iNO administered with a novel iNO-generator, for treating adults hospitalised for viral pneumonia. In this prospective, open-label, multicenter study, subjects aged 18-80, diagnosed with viral pneumonia received either standard supportive treatment alone (Control-Group) or combined with iNO for 40 min, 4 times per day up to 7 days (Treatment-Group). Out of 40 recruited subjects, 35 were included in the intention-to-treat population (34 with COVID-19). Adverse Events rate was similar between the groups (56.3% vs. 42.1%; respectively). No treatment-related adverse events were reported, while 2 serious adverse events were accounted for by underlying pre-existing conditions. Among the Treatment-Group, oxygen support duration was reduced by 2.7 days (Hazard Ratio = 2.8; p = 0.0339), a greater number of subjects reached oxygen saturation ≥ 93% within hospitalisation period (Hazard Ratio = 5.4; p = 0.049), and a trend for earlier discharge was demonstrated. Intermittent 150-ppm iNO-treatment is well-tolerated, safe, and beneficial compared to usual care for spontaneously breathing hospitalised adults diagnosed with COVID-19 viral pneumonia.

Fluid Resuscitation Dilemma in End-stage Renal Disease Patients Presenting with Sepsis: A Systematic Review and Meta-analysis

Background: This study aims to investigate the safety and efficacy of guideline-directed fluid resuscitation (GDFR) compared with conservative fluid management in end-stage renal disease (ESRD) patients with sepsis by evaluating 90-day mortality and intubation rate. Methods: Following PRISMA guidelines, a systematic review was conducted across multiple databases using specific keywords and controlled vocabulary. The search strategy, implemented until October 1, 2023, aimed to identify studies examining fluid resuscitation in ESRD patients with sepsis. The review process was streamlined using Covidence software. A fourth reviewer resolved discrepancies in study inclusion. A random-effects model with the generic Mantel-Haenszel method was preferred for integrating odds ratios (ORs). Sensitivity analysis and publication bias analysis were performed. Results: Of the 1274 identified studies, 10 were selected for inclusion, examining 1184 patients, 593 of whom received GDFR. Four studies were selected to investigate the intubation rate, including 304 patients. No significant mortality or intubation rate difference was spotted between both groups [OR = 1.23; confidence interval (CI) = 0.92-1.65; I2 = 0% and OR = 1.91; CI = 0.91-4.04]. In most studies, sensitivity analysis using the leave-one-out approach revealed higher mortality and intubation rates. The Egger test results indicated no statistically significant publication bias across the included studies. Conclusion: Our research contradicts the common assumption about the effectiveness of GDFR for sepsis patients with ESRD. It suggests that this approach, while not superior to the conservative strategy, may potentially be harmful.

A metabolomics pipeline highlights microbial metabolism in bloodstream infections

The growth of antimicrobial resistance (AMR) highlights an urgent need to identify bacterial pathogenic functions that may be targets for clinical intervention. Although severe infections profoundly alter host metabolism, prior studies have largely ignored microbial metabolism in this context. Here, we describe an iterative, comparative metabolomics pipeline to uncover microbial metabolic features in the complex setting of a host and apply it to investigate gram-negative bloodstream infection (BSI) in patients. We find elevated levels of bacterially derived acetylated polyamines during BSI and discover the enzyme responsible for their production (SpeG). Blocking SpeG activity reduces bacterial proliferation and slows pathogenesis. Reduction of SpeG activity also enhances bacterial membrane permeability and increases intracellular antibiotic accumulation, allowing us to overcome AMR in culture and in vivo. This study highlights how tools to study pathogen metabolism in the natural context of infection can reveal and prioritize therapeutic strategies for addressing challenging infections.

Endothelial progenitor cells for fabrication of engineered vascular units and angiogenesis induction

The promotion of vascularization and angiogenesis in the grafts is a crucial phenomenon in the healing process and tissue engineering. It has been shown that stem cells, especially endothelial progenitor cells (EPCs), can stimulate blood vessel formation inside the engineered hydrogels after being transplanted into the target sites. The incorporation of EPCs into the hydrogel can last the retention time, long-term survival, on-target delivery effects, migration and differentiation into mature endothelial cells. Despite these advantages, further modifications are mandatory to increase the dynamic growth and angiogenesis potential of EPCs in in vitro and in vivo conditions. Chemical modifications of distinct composites with distinct physical properties can yield better regenerative potential and angiogenesis during several pathologies. Here, we aimed to collect recent findings related to the application of EPCs in engineered vascular grafts and/or hydrogels for improving vascularization in the grafts. Data from the present article can help us in the application of EPCs as valid cell sources in the tissue engineering of several ischemic tissues.

When are pulmonologists consulted? Trends and outcomes of pulmonary consultations for unspecified hypoxia

Background

Clinical judgment is essential in determining the need for specialist consultation. We evaluated patients for whom the pulmonary team was consulted for unspecified hypoxia or acute hypoxic respiratory failure to better understand the characteristics and outcomes of such encounters.

Methods

We retrospectively studied patients who received consults for unspecified hypoxia or acute hypoxic respiratory failure at a tertiary center. Outcomes evaluated were length of stay, duration of follow-up, and clinical trajectory.

Results

We identified 103 patients over a 2-year period. The level of care was escalated in 69.9% (n = 72) of patients, and the majority had procedural interventions such as bronchoscopies and chest tube placement. Common diagnoses were pneumonia and volume overload. The mortality rate was 17.5% (n = 18). The mean length of stay was 24 days (standard deviation [SD] 24.1), with an average of 6.6 hospital days (SD 9.9) to consultation. The mean duration of consecutive follow-up was 4.5 days (SD 7.5). Patients who underwent procedures had a shorter duration of follow-up.

Conclusion

Pulmonary consults were noted for common diagnoses with a high need for escalation in care and procedural interventions, highlighting the importance and appropriateness of specialist consultations. Further studies are needed to explore what triggers an unspecified consult.

Advancing Pathogen Identification: The Role of Digital PCR in Enhancing Diagnostic Power in Different Settings

Digital polymerase chain reaction (dPCR) has emerged as a groundbreaking technology in molecular biology and diagnostics, offering exceptional precision and sensitivity in nucleic acid detection and quantification. This review highlights the core principles and transformative potential of dPCR, particularly in infectious disease diagnostics and environmental surveillance. Emphasizing its evolution from traditional PCR, dPCR provides accurate absolute quantification of target nucleic acids through advanced partitioning techniques. The review addresses the significant impact of dPCR in sepsis diagnosis and management, showcasing its superior sensitivity and specificity in early pathogen detection and identification of drug-resistant genes. Despite its advantages, challenges such as optimization of experimental conditions, standardization of data analysis workflows, and high costs are discussed. Furthermore, we compare various commercially available dPCR platforms, detailing their features and applications in clinical and research settings. Additionally, the review explores dPCR's role in water microbiology, particularly in wastewater surveillance and monitoring of waterborne pathogens, underscoring its importance in public health protection. In conclusion, future prospects of dPCR, including methodological optimization, integration with innovative technologies, and expansion into new sectors like metagenomics, are explored.

Naringin: A flavanone with a multifaceted target against sepsis-associated organ injuries

BACKGROUND

Sepsis causes multiple organ dysfunctions and raises mortality and morbidity rates through a dysregulated host response to infection. Despite the growing research interest over the last few years, no satisfactory treatment exists. Naringin, a naturally occurring bioflavonoid with vast therapeutic potential in citrus fruits and Chinese herbs, has received much attention for treating sepsis-associated multiple organ dysfunctions.

PURPOSE

The review describes preclinical evidence of naringin from 2011 to 2024, particularly emphasizing the mechanism of action mediated by naringin against sepsis-associated specific injuries. The combination therapy, safety profile, drug interactions, recent advancements in formulation, and future perspectives of naringin are also discussed.

METHODS

In vivo and in vitro studies focusing on the potential role of naringin and its mechanism of action against sepsis-associated organ injuries were identified and summarised in the present manuscript, which includes contributions from 2011 to 2024. All the articles were extracted from the Medline database using PubMed, Science Direct, and Web of Science with relevant keywords.

RESULTS

Research findings revealed that naringin modulates many signaling cascades, such as Rho/ROCK and PPAR/STAT1, PIP3/AKT and KEAP1/Nrf2, and IkB/NF-kB and MAPK/Nrf2/HO-1, to potentially protect against sepsis-induced intestinal, cardiac, and lung injury, respectively. Furthermore, naringin treatment exhibits anti-inflammatory, anti-apoptotic, and antioxidant action against sepsis harm, highlighting naringin's promising effects in septic settings. Naringin could be employed as a treatment against sepsis, based on studies on combination therapy, synergistic effects, and toxicological investigation that show no reported severe side effects.

CONCLUSION

Naringin might be a promising therapeutic approach for preventing sepsis-induced multiple organ failure. Naringin should be used alongside other therapeutic therapies with caution despite its great therapeutic potential and lower toxicity. Nonetheless, clinical studies are required to comprehend the therapeutic benefits of naringin against sepsis.

Hypoalbuminemia is Highly Prevalent in Patients with Periprosthetic Joint Infection and Strongly Associated with Treatment Failure

OBJECTIVE

The role of hypoalbuminemia throughout the course of chronic periprosthetic joint infection (PJI) remains poorly understood. This study aimed to determine the prevalence and risk factors of hypoalbuminemia in periprosthetic joint infection (PJI) patients and to explore the association between hypoalbuminemia and treatment outcomes.

METHODS

This retrospective cohort study included 387 PJI cases who underwent two-stage exchange arthroplasty between January 2007 and August 2020, of which 342 were reimplanted. The mean follow-up period was 7.9 years. Multivariate logistic regression analyses were performed to identify risk factors for hypoalbuminemia and to assess the effect of hypoalbuminemia at 1st- and 2nd-stage exchange on the treatment outcome. Furthermore, the impact of dynamic changes in hypoalbuminemia was investigated.

RESULTS

The prevalence of hypoalbuminemia at 1st- and 2nd-stage exchange was 22.2% and 4.7%, respectively. Patients with age ≥ 68 years and those with isolation of Staphylococcus aureus, Streptococcus, or Gram-negative bacteria exhibited a higher risk of hypoalbuminemia. Hypoalbuminemia at 1st-stage was significantly related to treatment failure (OR = 3.3), while hypoalbuminemia at 2nd-stage raised the OR to 10.0. Patients with persistent hypoalbuminemia at both the 1st- and 2nd-stage exchanges had a significantly higher rate of treatment failure than patients with hypoalbuminemia at the 1st-stage but normal albumin levels at the 2nd-stage exchange (55.6% vs 20.0%, p = 0.036).

CONCLUSION

One in five patients with chronic PJI exhibits hypoalbuminemia. Hypoalbuminemia is more likely to develop in patients of advanced age and those infected by specific highly virulent organisms. Also, our results highlight the close association between hypoalbuminemia and treatment outcomes.

Revealing the Hidden Impacts: Insights into Biological Aging and Long-Term Effects in Pauci- and Asymptomatic COVID-19 Healthcare Workers

This study explores the role of inflammation and oxidative stress, hallmarks of COVID-19, in accelerating cellular biological aging. We investigated early molecular markers-DNA methylation age (DNAmAge) and telomere length (TL)-in blood leukocytes, nasal cells (NCs), and induced sputum (IS) one year post-infection in pauci- and asymptomatic healthcare workers (HCWs) infected during the first pandemic wave (February-May 2020), compared to COPD patients, model for "aged lung". Data from questionnaires, Work Ability Index (WAI), blood analyses, autonomic cardiac balance assessments, heart rate variability (HRV), and pulmonary function tests were collected. Elevated leukocyte DNAmAge significantly correlated with advancing age, male sex, daytime work, and an aged phenotype characterized by chronic diseases, elevated LDL and glycemia levels, medications affecting HRV, and declines in lung function, WAI, lymphocyte count, hemoglobin levels, and HRV (p < 0.05). Increasing age, LDL levels, job positions involving intensive patient contact, and higher leukocyte counts collectively contributed to shortened leukocyte TL (p < 0.05). Notably, HCWs exhibited accelerated biological aging in IS cells compared to both blood leukocytes (p ≤ 0.05) and NCs (p < 0.001) and were biologically older than COPD patients (p < 0.05). These findings suggest the need to monitor aging in pauci- and asymptomatic COVID-19 survivors, who represent the majority of the general population.

Assessing Evidence-Based Practice Knowledge, Self-Efficacy, and Use Among Respiratory Therapists

BACKGROUND

Evidence-based practice is at the forefront of providing quality patient care by using the best available evidence and clinical expertise, while also considering patient needs and preferences for clinical decisions. However, evidence-based practice may not be consistently used even when the evidence supports the therapy. The purpose of this study was to assess the factors associated with the use of evidence-based practice among respiratory therapy faculty teaching in a large community college system and post-professional students enrolled in a university-based, respiratory therapy baccalaureate degree-advancement program.

METHODS

A non-probability, descriptive survey research design was used to develop and administer an online questionnaire.

RESULTS

All respondents demonstrated sufficient knowledge and understanding of introductory concepts of evidence-based practice but knowledge of specific components of the evidence-based practice process was not as strong. Self-efficacy in knowledge and the use of evidence-based practice among faculty and degree-advancement students varied. Faculty and students rated their self-efficacy high in assessing patients' needs, values, and treatment preferences but ratings were lower for using the PICO (patient/population/problem, intervention, comparison, outcome) technique and interpreting common statistical tests. Students viewed their previous evidence-based practice learning experiences more favorably compared with faculty (P = .008). Faculty and students searched and read the research literature more often compared with critically appraising and using the research literature. Logistic regression analysis indicated no statistically significant relationship of knowledge, self-efficacy, and learning experiences to the use of evidence-based practice among respiratory therapy students, Χ 2 (4, N = 54) = 7.73; P = .10.

CONCLUSIONS

Analysis of the results suggested that respiratory therapy faculty and students were knowledgeable and confident with regard to evidence-based practice but their use of evidence-based practice in clinical decisions was limited. Although the evidence-based practice knowledge, self-efficacy, and learning experiences had minimal influence on the use of evidence-based practice, the results of the study provide a foundation for future research.

Feasibility and safety of interactive virtual reality upper limb rehabilitation in patients with prolonged critical illness

OBJECTIVES

This study investigated the feasibility and safety of interactive virtual reality rehabilitation (VRR) for patients with a critical illness and a long stay in the intensive care unit (ICU), as a motivational tool for rehabilitation.

DESIGN

Single-centre, non-randomised proof-of-concept clinical trial.

PARTICIPANTS

Adult, calm, and alert critically ill patients with a prolonged stay (≥8 days) in the ICU.

METHODS

Patients received interactive VRR therapy for upper limb rehabilitation with a VR-app designed specifically for use in bedridden patients in the supine position. Feasibility was assessed by time registrations, questionnaires for patients and physiotherapists, as well as recording of all perceived barriers. Safety was assessed by recording (changes in) vital clinical parameters, as well as minor and major adverse events.

RESULTS

Twenty patients participated in 79 VRR sessions. Median durations of different session components were 2 minutes (interquartile range [IQR] = 2min, 3min) for set-up and explanation to the patient, 10 minutes (IQR = 10min, 15min) for training time, and 2 minutes (IQR = 2min, 2min) for ending the session and cleaning. The median fun score given by the patients after each session was 9 (IQR = 8, 10) out of 10. Physiotherapists reported no barriers other than a few time-consuming technical problems. Reported problems by patients were all minor and mostly technical. No major and no minor adverse events occurred.

CONCLUSIONS

Interactive upper limb VRR is a feasible, safe, and appreciated tool to use in rehabilitation of critically ill patients during their prolonged ICU stay. Subsequent future studies should focus on the effects of VRR on neuromuscular and cognitive function and the socioeconomic impact of exergaming for rehabilitation purposes of ICU patients.