The impact of lung surgery, with or without (neo-)adjuvant therapy, on physical functioning in patients with nonsmall cell lung cancer: a scoping review

BACKGROUND

Patients with early stage (I-IIIA) nonsmall cell lung cancer (NSCLC) are typically treated via surgery, often accompanied by (neo-)adjuvant therapy. These interventions impose a significant burden on patients and potentially impact their physical functioning (PF). The impact on PF remains uncertain and existing evidence has not yet been systematically outlined.

OBJECTIVE

This scoping review aimed to synthesise evidence concerning the effects of lung surgery, with or without (neo-)adjuvant therapy, on the PF of patients with NSCLC.

METHODS

PubMed, Web of Science and Cochrane databases were systematically searched from inception until 1 July 2023. A comprehensive framework based on the International Classification of Functioning, Disability, and Health was used to define various aspects of PF. Longitudinal studies, reporting PF prior to and after NSCLC treatment, and cross-sectional studies reporting PF after treatment were included.

RESULTS

85 included studies assessed the effects of surgery with (n=7) or without (n=78) (neo-) adjuvant therapy on body function (n=29), activity (n=67) and/or participation (n=15). 98% of reported outcomes within the longitudinal studies indicate a decline in PF, with 52% demonstrating significant deteriorations, with follow-up times ranging from immediately post-operative up to 1 year after treatment. Cross-sectional studies show impaired PF in 71% of reported outcomes.

CONCLUSION

PF of patients with NSCLC tends to deteriorate following lung surgery, irrespective of additional (neo-)adjuvant therapy. While the negative impact of lung surgery on ICF categories of "body function" and "activity" have been described to some depth, insights into the impact on "participation" are lacking.

Evaluation of Nutritional, Phytochemical, Fatty Acids and Mineral Composition of Eremurus robustus Leaves in Bradost Mountain, Kurdistan Region of Iraq

One of the wild herbs that grows naturally in the springtime in Kurdistan's mountainous regions is Eremurus robustus. The study aimed to detect the proximate analysis, polyphenols, fatty acid profile, and mineral composition in the leaves of Eremurus robustus. Proximate composition revealed it is a source of vitamin C, fiber, and protein. Nine phenolic compounds and 24 fatty acids were detected, along with 14 saturated and 10 unsaturated fatty acids using high-performance liquid chromatography (HP-LC) and gas chromatography-mass spectrophotometers (GC-MS). Seventeen mineral compositions were found using an inductively coupled spectrophotometric technique. Vegetable trace metal concentrations can be assessed by comparing the daily diets of plants and humans. The research suggests that Eremurus robustus leaves can serve as nutritional supplements and functional foods, not just for therapeutic uses.

I Brazilian guideline on hypertension in dialysis of the Brazilian Society of Nephrology

Hypertension in dialysis patients (HTND) has a high prevalence, affecting at least 80% or more of patients, and its management in the nephrology practice is heterogeneous and often empirical. Knowing how to define, understand the pathophysiology, diagnose, monitor and treat with lifestyle changes, and adjust antihypertensive drugs to achieve the recommended blood pressure (BP) target - to reduce morbidity and mortality - requires specific knowl-edge and approaches within the contexts of hemodialysis (HD) and peritoneal dialysis (PD). This document is the first guideline of the Brazilian Society of Nephrology, developed by the departments of Hypertension and Dialysis. It aims to guide physicians who provide care in dialysis centers on how to manage patients with HTND, in a comprehensive and individualized manner, based on the critical appraisal of the best available scientific evidence. When such evidence is scarce or unavailable, the opinion of specialists should be recommended. The different topics covered include HTND definition (pre-HD BP ≥ 140/90 mmHg and post-HD BP ≥ 130/80 mmHg), epidemiology, and pathophysiology; diagnosis of HTND preferably with BP measurements outside the dialysis setting (BP ≥ 130/80 mmHg); complementary assessment; blood pressure targets; non-pharmacological treatment; use of the most appropriate antihypertensive medications; special situations; and complications of HTND, predominantly cardiovascular ones.

Trauma Center model application in the University Hospital of Pisa: a single-center comparative study

The Trauma Center, Hub, is a highly specialized hospital indicated for complex major trauma management after stabilization at a 1st level hospital, Spoke. Although in the United States this organization demonstrated its effectiveness in mortality, in the Italian context, data available are limited. On 30 September 2018, the University Hospital of Pisa formalized the introduction of the Trauma Center, optimizing Emergency Department (ED) organization to guarantee the highest standard of care. The aim of this study was to demonstrate that the new model led better outcomes. We conducted a comparative retrospective study on 1154 major traumas over 24 months: the first 12 months (576 patients) correspond to the period before Trauma Center introduction, and the following 12 (457 patients) to the subsequent period. Results showed increase in greater dynamics and primary centralization by helicopter (p < 0.001, p 0.006). A systematic assessment with ABCDE algorithm was performed in a higher number of patients in the most recent period, from 38.4% to 80.3% (p < 0.001). Focused Assessment with Sonography for Trauma (FAST) performed by the emergency doctor increased after Trauma Center introduction, p value < 0.001. The data show an increase of ATLS certification among staff from 51.9 to 71.4% and a reduction in early and late mortality after the Trauma Center introduction (p value 0.05 and < 0.01). Fewer patients required intensive and surgical treatments, with a shorter hospital stay. The results demonstrate the advantage in terms of outcomes in the organization of the Trauma Center in the Italian context.

Influence of hydrocortisone infusion method on the clinical outcome of patients with septic shock: A systematic review and meta-analysis

Background

The effect of the modality of hydrocortisone administration on clinical outcomes in patients with septic shock remains uncertain. This systematic review and meta-analysis evaluate the impact of intermittent bolus and continuous infusion of hydrocortisone on these outcomes.

Methods

We searched the PubMed, Embase databases, and Cochrane Library for randomized controlled trials (RCTs) and cohort studies published from inception to January 1, 2023. We included studies involving adult patients with septic shock. All authors reported our primary outcome of short-term mortality and clearly compared the clinically relevant secondary outcomes (ICU length of stay, hospital length of stay, vasopressor-free days, hyperglycemia, hypernatremia, and ICU-acquired weakness [ICUAW]) of intermittent bolus and continuous infusion of hydrocortisone. Results were expressed as odds ratio (OR) and mean difference (MD) with accompanying 95% confidence interval (CI). The PROSPERO registration number is CRD42023392160.

Results

Seven studies, including 554 patients, were included. The primary outcome of this meta-analysis showed no statistically significant difference in the short-term mortality between intermittent bolus and continuous infusion groups (OR=1.21, 95% CI: 0.84 to 1.73; P=0.31; Chi2 =9.06; I 2=34%). Secondary outcomes showed no statistically significant difference in the ICU length of stay (MD=-0.15, 95% CI: -2.31 to 2.02; P=0.89; Chi2 =0.95; I 2=0%), hospital length of stay (MD=0.63, 95% CI: -4.24 to 5.50; P=0.80; Chi2 =0.61; I 2=0%), vasopressor-free days (MD=-1.18, 95% CI: -2.43 to 0.06; P=0.06; Chi2 =2.48; I 2=60%), hyperglycemia (OR=1.27, 95% CI: 0.80 to 2.02; P=0.31; Chi2 =5.23; I 2=43%), hypernatremia (OR=0.93, 95% CI: 0.44 to 1.96; P=0.85; Chi2 =0.37; I 2=0%), or ICUAW (OR=0.83, 95% CI: 0.36 to 1.94; P=0.67; Chi2 =0.90; I 2=0%) between the two groups.

Conclusions

This meta-analysis indicated no significant difference in short-term mortality between intermittent bolus or continuous hydrocortisone infusion in patients with septic shock. Additionally, the hydrocortisone infusion method was not associated with ICU length of stay, hospital length of stay, vasopressor-free days, hyperglycemia, hypernatremia, or ICUAW.

Mortality-associated plasma proteome dynamics in a prospective multicentre sepsis cohort

BACKGROUND

Sepsis remains a leading cause of mortality in intensive care units. Understanding the dynamics of the plasma proteome of patients with sepsis is critical for improving prognostic and therapeutic strategies.

METHODS

This prospective, multicentre observational cohort study included 363 patients with sepsis recruited from five university hospitals in Germany between March 2018 and April 2023. Plasma samples were collected on days 1 and 4 after sepsis diagnosis, and proteome analysis was performed using mass spectrometry. Classical statistical methods and machine learning (random forest) were employed to identify proteins associated with 30-day survival outcomes.

FINDINGS

Out of 363 patients, 224 (62%) survived, and 139 (38%) did not survive the 30-day period. Proteomic analysis revealed significant differences in 87 proteins on day 1 and 95 proteins on day 4 between survivors and non-survivors. Additionally, 63 proteins were differentially regulated between day 1 and day 4 in the two groups. The identified protein networks were primarily related to blood coagulation, immune response, and complement activation. The random forest classifier achieved an area under the receiver operating characteristic curve of 0.75 for predicting 30-day survival. The results were compared and partially validated with an external sepsis cohort.

INTERPRETATION

This study describes temporal changes in the plasma proteome associated with mortality in sepsis. These findings offer new insights into sepsis pathophysiology, emphasizing the innate immune system as an underexplored network, and may inform the development of targeted therapeutic strategies.

FUNDING

European Regional Development Fund of the European Union. The State of North Rhine-Westphalia, Germany.

Can a breast hematoma lead to hemorrhagic shock in elderly trauma patients with multiple comorbidities and reduced physiological reserve? Examining the risks and management strategies

Breast trauma in elderly patients with multiple comorbidities can result in severe complications such as hemorrhagic shock due to the highly vascular nature of breast tissue. This case involves a 65-year-old female with a history of rheumatoid arthritis and prior breast cancer who developed a significant breast hematoma following a motor vehicle accident. Initially stable, she rapidly deteriorated with hypotension and altered mental status after imaging revealed a large hematoma with active hemorrhage. Immediate intervention, including blood transfusion and intubation, was essential for stabilization. While spontaneous cessation of bleeding and hematoma stabilization can negate the need for further intervention, persistent bleeding requires prompt action. Options include surgical exploration, hematoma evacuation, vessel ligation, interventional radiology for embolization, additional blood transfusions, and pharmacological hemostatic agents. Breast hematoma can lead to hemorrhagic shock if severe enough in elderly patients with reduced physiological reserve.

Methanol Induced Optic Neuropathy: Molecular Mysteries, Public Health Perspective, Clinical Insights and Treatment Strategies

Methanol-induced optic neuropathy (MION) represents a critical public health issue, particularly prevalent in lower socioeconomic populations and regions with restricted alcohol access. MION, characterized by irreversible visual impairment, arises from the toxic metabolization of methanol into formaldehyde and formic acid, leading to mitochondrial oxidative phosphorylation inhibition, oxidative stress, and subsequent neurotoxicity. The pathogenesis involves axonal and glial cell degeneration within the optic nerve and potential retinal damage. Despite advancements in therapeutic interventions, a significant proportion of affected individuals endure persistent visual sequelae. The study comprehensively investigates the pathophysiology of MION, encompassing the absorption and metabolism of methanol, subsequent systemic effects, and ocular impacts. Histopathological changes, including alterations in retinal layers and proteins, Müller cell dysfunction, and visual symptoms, are meticulously examined to provide insights into the disease mechanism. Furthermore, preventive measures and public health perspectives are discussed to highlight the importance of awareness and intervention strategies. Therapeutic approaches, such as decontamination procedures, ethanol and fomepizole administration, hemodialysis, intravenous fluids, electrolyte balance management, nutritional therapy, corticosteroid therapy, and erythropoietin (EPO) treatment, are evaluated for their efficacy in managing MION. This comprehensive review underscores the need for increased awareness, improved diagnostic strategies, and more effective treatments to mitigate the impact of MION on global health.

Flexible fibreoptic bronchoscopy is beneficial in children on extracorporeal membrane oxygenation support

BACKGROUND

Flexible fibreoptic bronchoscopy (FFB) has the potential to enhance diagnostic capabilities and improve pulmonary function in children on extracorporeal membrane oxygenation (ECMO).

OBJECTIVES

The objective of this study was to evaluate the benefits (clinical, radiological, and microbiological) of FFB and assess associated complications in children on ECMO.

METHODS

We conducted a single-centre retrospective observational cohort study in a tertiary paediatric intensive care unit. All FFB episodes performed during the study period on children aged 0-18 years on ECMO were included.

RESULTS

Out of the 155 children who received ECMO, 36 (23%) underwent a total of 92 episodes of FFB. FFB provided anatomical and pathological information in 53% (19/36) of cases and proved beneficial in clearing the airways in 62% (54/87) of the episodes. Overall, patients exhibited transient increases in ECMO and mechanical ventilation support 1 h post FFB in 14% (13/92) and 9.7% (9/92) episodes, respectively. At 6 h, the mean fraction of inspired oxygen on the mechanical ventilator was lower (0.46 [±0.21] vs 0.53 [±0.21] p < 0.01), with no change in mean airway pressure. Similarly, compared to pre-FFB, the fraction of inspired oxygen on the mechanical ventilator on ECMO was lower at 6 h and 24 h (0.65 [±0.25] vs 0.71 [±0.23] p < 0.01 and 0.006, respectively), with no significant change in the sweep gas flow and ECMO flow. The radiological imaging indicated improved or stable findings in 91% (83/91) of FFB episodes. FFB contributed to the identification of new and previously unknown microbiological information in 75% (27/36) of the patients. The incidence of major complications was 7.6%. Minor self-resolving bleeding occurred in 25% (23/92) episodes, and major bleeding occurred in two episodes, with a total of 10 episodes needing blood product transfusion.

CONCLUSIONS

FFB is a valuable adjunct in managing children with severe respiratory failure on ECMO, offering clinical benefits with a low rate of major complications. Further studies should aim to develop a consensus approach encompassing criteria and clinical management around FFB in patients on ECMO.

Concurrent use of continuous kidney replacement therapy during extracorporeal membrane oxygenation: what pediatric nephrologists need to know-PCRRT-ICONIC practice points

Extracorporeal membrane oxygenation (ECMO) provides temporary cardiorespiratory support for neonatal, pediatric, and adult patients when traditional management has failed. This lifesaving therapy has intrinsic risks, including the development of a robust inflammatory response, acute kidney injury (AKI), fluid overload (FO), and blood loss via consumption and coagulopathy. Continuous kidney replacement therapy (CKRT) has been proposed to reduce these side effects by mitigating the host inflammatory response and controlling FO, improving outcomes in patients requiring ECMO. The Pediatric Continuous Renal Replacement Therapy (PCRRT) Workgroup and the International Collaboration of Nephrologists and Intensivists for Critical Care Children (ICONIC) met to highlight current practice standards for ECMO use within the pediatric population. This review discusses ECMO modalities, the pathophysiology of inflammation during an ECMO run, its adverse effects, various anticoagulation strategies, and the technical aspects and outcomes of implementing CKRT during ECMO in neonatal and pediatric populations. Consensus practice points and guidelines are summarized. ECMO should be utilized in patients with severe acute respiratory failure despite the use of conventional treatment modalities. The Extracorporeal Life Support Organization (ELSO) offers guidelines for ECMO initiation and management while maintaining a clinical registry of over 195,000 patients to assess outcomes and complications. Monitoring and preventing fluid overload during ECMO and CKRT are imperative to reduce mortality risk. Clinical evidence, resources, and experience of the nephrologist and healthcare team should guide the selection of ECMO circuit.

Reprint of: M1 macrophage-targeted curcumin nanocrystals with l-arginine-modified for acute lung injury by inhalation

Acute Lung Injury/Acute Respiratory Distress Syndrome (ALI/ARDS) with clinical manifestations of respiratory distress and hypoxemia remains a significant cause of respiratory failure, boasting a persistently high incidence and mortality rate. Given the central role of M1 macrophages in the pathogenesis of acute lung injury (ALI), this study utilized the anti-inflammatory agent curcumin as a model drug. l-arginine (L-Arg) was employed as a targeting ligand, and chitosan was initially modified with l-arginine. Subsequently, it was utilized as a surface modifier to prepare inhalable nano-crystals loaded with curcumin (Arg-CS-Cur), aiming for specific targeting of pulmonary M1 macrophages. Compared with unmodified chitosan-curcumin nanocrystals (CS-Cur), Arg-CS-Cur exhibited higher uptake in vitro by M1 macrophages, as evidenced by flow cytometry showing the highest fluorescence intensity in the Arg-CS-Cur group (P < 0.01). In vivo accumulation was greater in inflamed lung tissues, as indicated by small animal imaging demonstrating higher lung fluorescence intensity in the DiR-Arg-CS-Cur group compared to the DiR-CS-Cur group in the rat ALI model (P < 0.05), peaking at 12 h. Moreover, Arg-CS-Cur demonstrated enhanced therapeutic effects in both LPS-induced RAW264.7 cells and ALI rat models. Specifically, treatment with Arg-CS-Cur significantly suppressed NO release and levels of TNF-α and IL-6 in RAW264.7 cells (p < 0.01), while in ALI rat models, expression levels of TNF-α and IL-6 in lung tissues were significantly lower than those in the model group (P < 0.01). Furthermore, lung tissue damage was significantly reduced, with histological scores significantly lower than those in the CS-Cur group (P < 0.01). In conclusion, these findings underscore the targeting potential of l-arginine-modified nanocrystals, which effectively enhance curcumin concentration in inflammatory environments by selectively targeting M1 macrophages. This study thus introduces novel perspectives and theoretical support for the development of targeted therapeutic interventions for acute inflammatory lung diseases, including ALI/ARDS.

Enhanced Hemodynamics of Anisometric TPMS Topology Reduce Blood Clotting in 3D Printed Blood Contactors

Artificial organs, such as extracorporeal membrane oxygenators, dialyzers, and hemoadsorber cartridges, face persistent challenges related to the flow distribution within the cartridge. This uneven flow distribution leads to clot formation and inefficient mass transfer over the device's functional surface. In this work, a comprehensive methodology is presented for precisely integrating triply periodic minimal surfaces (TPMS) into module housings and question whether the internal surface topology determining the flow distribution affects blood coagulation. Three module types are compared with different internal topologies: tubular, isometric, and anisometric TPMS. First, this study includes a computational fluid dynamics (CFD) simulation of the internal hemodynamics, validated through experimental residence time distributions (RTD). Blood tests using human whole blood and subsequent visualization of blood clots by computed tomography, allow the quantification of structure-induced blood clotting. The results indicate that TPMS topologies, particularly anisometric ones, serve as effective flow distributors and significantly reduce and delay blood clotting compared to conventional tubular geometries. For these novel TPMS modules, the inner surfaces can be activated chemically or functionalized to function as a selective adsorption site or biocatalytic surface or made of a permeable material to facilitate mass transfer.

Anticoagulation Can Be Held in Traumatically Injured Patients on Veno-Venous Extracorporeal Membrane Oxygenation Support

Traumatic injury is associated with several pulmonary complications, including pulmonary contusion, transfusion-related acute lung injury (TRALI), and the development of acute respiratory distress syndrome (ARDS). There is a lack of literature on these patients supported with veno-venous extracorporeal oxygenation (VV ECMO). Understanding the safety of using VV ECMO to support trauma patients and the ability to hold anticoagulation is important to broaden utilization. This is a single-center retrospective cohort study of adult trauma patients cannulated for VV ECMO during their initial admission over an 8 year period (2014-2021). We hypothesize that anticoagulation can be held in trauma patients on VV ECMO without increasing mortality or prothrombotic complications. We also describe the coagulopathy of traumatically injured patients on VV ECMO. Withholding anticoagulation was not associated with mortality in our study population, and there were no significant differences in bleeding or clotting complications between patients who did and did not receive systemic anticoagulation. Patients in the nonsurvivor group had increased coagulopathy both pre- and post-cannulation. Our study suggests anticoagulation can be safely withheld in traumatically injured VV ECMO patients without increasing mortality, complication rates, or transfusion requirements. Future, multicenter prospective studies with larger sample sizes are required to confirm our results.

The Effectiveness of the International Trauma Life Support (ITLS) Course on Multidisciplinary Healthcare Providers

BACKGROUND

The International Trauma Life Support (ITLS) course is designed to enhance the trauma management skills of healthcare providers. Our study aimed to assess the effectiveness of the ITLS course in improving trauma knowledge among multidisciplinary healthcare professionals.

METHODS

A pre/post research design was used, involving 28 participants who completed both pre- and post-course assessments. Paired sample t-tests and chi-square tests were performed to compare pre- and post-test scores and explore the relationships between demographic characteristics and score changes.

RESULTS

The ITLS course significantly improved trauma-related knowledge among the participants, with the mean pre-test score rising from 82.4 (SD = 4.3) to 88.7 (SD = 3.6) post-test (p < 0.001). Post-test scores were significantly higher for those with postgraduate qualifications (89.9 ± 3.6, p = 0.035) and those who had more than 15 years of experience (88.9 ± 1.7, p < 0.001). The participants reported high satisfaction with the course, with a mean score of 3.56 out of 5, indicating positive reception and perceived effectiveness.

CONCLUSION

The ITLS course significantly improved the trauma-related knowledge of healthcare providers across multiple disciplines. Participants with multiple years of experience and those with postgraduate degrees were more likely to have higher post-test scores. Participants reported high satisfaction with the course.

Individualized autoregulation-guided arterial blood pressure management in neurocritical care

Cerebral autoregulation (CA) is the physiological process by which cerebral blood flow is maintained during fluctuations in arterial blood pressure (ABP). There are various validated methods to measure CA, either invasively, with intracranial pressure or brain tissue oxygenation monitors, or noninvasively, with transcranial Doppler ultrasound or near-infrared spectroscopy. Utilizing these monitors, researchers have been able to discern CA patterns in several pathological states, such as but not limited to acute ischemic stroke, spontaneous intracranial hemorrhage, aneurysmal subarachnoid hemorrhage, sepsis, and post-cardiac arrest, and they have found CA to be altered in these patients. CA disturbances predispose patients suffering from these ailments to worse outcomes. Much focus has been placed on CA monitoring in these populations, with an emphasis on arterial blood pressure optimization. Many guidelines recommend universal static ABP targets; however, in patients with altered CA, these targets may make them susceptible to hypoperfusion and further neurological injury. Based on this observation, there has been much investigation on individualized ABP goals and their effect on clinical outcomes. The scope of this review includes (1) a summary of the physiology of CA in healthy adults; (2) a review of the evidence on CA monitoring in healthy individuals; (3) a summary of CA changes and its effect on outcomes in various diseased states including acute ischemic stroke, spontaneous intracranial hemorrhage, aneurysmal subarachnoid hemorrhage, sepsis and meningitis, post-cardiac arrest, hypoxic-ischemic encephalopathy, surgery, and moyamoya disease; and (4) a review of the current evidence on individualized ABP changes in various patient populations.

SARS-CoV-2 Viral Load and Cytokine Dynamics Profile as Early Signatures of Long COVID Condition in Hospitalized Individuals

BACKGROUND

The global pandemic caused by SARS-CoV-2 has resulted in millions of people experiencing long COVID condition, a range of persistent symptoms following the acute phase, with an estimated prevalence of 27%-64%.

MATERIALS AND METHODS

To understand its pathophysiology, we conducted a longitudinal study on viral load and cytokine dynamics in individuals with confirmed SARS-CoV-2 infection. We used reverse transcriptase droplet digital PCR to quantify viral RNA from nasopharyngeal swabs and employed multiplex technology to measure plasma cytokine levels in a cohort of people with SARS-CoV-2 infection. Our study included individuals with long COVID condition and those without, all of whom had at least three nasopharyngeal and plasma samples collected within 55 days after diagnosis of SARS-CoV-2 infection.

RESULTS

Individuals affected with long COVID symptoms had delayed viral clearance and lower viral loads at diagnosis compared to those without symptoms. Additionally, cytokine analysis revealed variations in IL-18, MIG, and IP-10 levels, with delayed normalization in individuals affected by long COVID syndrome. Correlation analysis indicated associations between viral load and IP-10 and interrelations among cytokines IL-1β, IL-18, MIG, and IP-10.

CONCLUSION

Our study provides insights into the association between nasopharyngeal viral load, cytokine dynamics, and the development of long COVID syndrome, providing an early signature of this condition.

Survival Rate in Emergency Thoracotomy for Penetrating Trauma: A Retrospective Cross-Sectional Study

Background Emergency thoracotomy (ET) is a critical intervention for traumatic thoracic injuries, often required in patients with penetrating trauma. The survival outcomes and the factors that influence survival in these patients remain an area of interest for trauma care providers. Objective The objective of the study is to assess the survival rate and factors influencing the survival of patients undergoing emergency thoracotomy due to penetrating thoracic trauma. Methods This retrospective cross-sectional study was conducted in the thoracic surgery, accident, and emergency department of Lady Reading Hospital, Peshawar, Pakistan. A total of 85 patients who underwent emergency thoracotomy following penetrating trauma between July 2019 and June 2024 were included. Data were extracted from the health information management system (HIMS) and analyzed using SPSS. The study reviewed demographic details, severity of injury, operative details, and postoperative outcomes. Statistical analyses included univariate analysis using chi-square and Fisher's exact tests for categorical data and independent t-tests for continuous variables. Results The study included 85 patients with a mean age of 25.72±7.84 years. The majority of patients were male (81/85, 95.29%), while females accounted for a smaller proportion (4/85, 4.71%), and gunshot trauma accounted for the most frequent cause of penetrating injury (50/85, 58.8%). The time to thoracotomy was within 60 minutes of admission, with a mean time of 48±16.5 minutes. A total of 61/85 (71.5%) patients had isolated thoracic injuries, and 24/85 (28.2%) had associated injuries, with 24/85 (28.2%) patients requiring concomitant laparotomy. The overall mortality rate was 9/85 (10.5%), with 7/9 (77.7%) of deaths occurring intraoperatively. Mortality was significantly higher in patients with combined thoracotomy and laparotomy procedures. Prolonged hospital stays and higher transfusion requirements were observed in gunshot wound victims (50/85, 58.8%). Conclusions Emergency thoracotomy for penetrating thoracic trauma has a significant mortality rate in patients with combined thoracic and abdominal injuries. Factors such as the mechanism of injury, associated injuries, and the need for additional procedures (e.g., laparotomy) influence survival outcomes. Early intervention and proper management of associated injuries are crucial for improving survival rates in these patients.

Ethyl chloride poisoning from inhalational misuse: clinical features and outcomes

INTRODUCTION

Ethyl chloride misuse remains a prevailing concern due to its accessibility, but detailed descriptions of the features of toxicity are limited to sporadic reports, resulting in knowledge gaps in their clinical features and diagnosis.

OBJECTIVE

To describe the clinical features, treatment, and outcomes of patients reported in the literature who developed toxicity from inhalational use of ethyl chloride.

METHODS

We reviewed relevant literature over the past 50 years and analyzed the characteristics and outcomes of patients with toxicity from the inhalational use of ethyl chloride.

RESULTS

A total of 21 studies from 1979 to 2024 were identified, making available 22 patients for analysis. Their median age was 40 years (range 16-62 years), and there were more than four times as many males as females. Ethyl chloride-containing cleaning solvents (8/22, 36%) were most commonly used. Regular inhalation of ethyl chloride was documented in approximately two-thirds of the patients (14/22, 66%), with a median duration of five months of misuse (range 2-360 months). A large proportion of patients (15/22, 68%) inhaled ethyl chloride again within a week from the onset of toxicity. Although features of cerebellar dysfunction were very common at presentation (13/16, 81%), abnormalities on neuroimaging studies were rare. Death occurred in more than a quarter of cases (6/22, 27%), with patients either already deceased or dying shortly after. Half (3/6) of these deaths were directly attributable to the development of lethal cardiac dysrhythmias. Conversely, most survivors either improved or fully recovered within a few days to weeks (14/16, 88%), independent of their presenting symptoms, clinical signs, and the treatments they received.

DISCUSSION

Ethyl chloride users are likely young or middle-aged males, and clinical features of toxicity can range from transient neurological symptoms to cardiac dysrhythmias and death. The prominence of neurotoxicity may be attributed to the lipophilic nature of ethyl chloride and its tendency to accumulate in neural tissue, while cardiac dysrhythmias have been attributed to cardiac sensitization to catecholamines through ethyl chloride-induced inhibition of potassium, calcium, and sodium channels.

CONCLUSIONS

Toxicity from the inhalational misuse of ethyl chloride should be considered in young or middle-aged males presenting with acute cerebellar dysfunction. We recommend that suspected cases undergo telemetric monitoring for 24 h, especially when tachycardia and/or palpitations are present, as deaths from lethal cardiac dysrhythmias are not uncommon.

Intestinal oxygen utilisation and cellular adaptation during intestinal ischaemia-reperfusion injury

The gastrointestinal tract can be deranged by ailments including sepsis, trauma and haemorrhage. Ischaemic injury provokes a common constellation of microscopic and macroscopic changes that, together with the paradoxical exacerbation of cellular dysfunction and death following restoration of blood flow, are collectively known as ischaemia-reperfusion injury (IRI). Although much of the gastrointestinal tract is normally hypoxemic, intestinal IRI results when there is inadequate oxygen availability due to poor supply (pathological hypoxia) or abnormal tissue oxygen use and metabolism (dysoxia). Intestinal oxygen uptake usually remains constant over a wide range of blood flows and pressures, with cellular function being substantively compromised when ischaemia leads to a >50% decline in intestinal oxygen consumption. Restoration of perfusion and oxygenation provokes additional injury, resulting in mucosal damage and disruption of intestinal barrier function. The primary cellular mechanism for sensing hypoxia and for activating a cascade of cellular responses to mitigate the injury is a family of heterodimer proteins called hypoxia-inducible factors (HIFs). The HIF system is connected to numerous biochemical and immunologic pathways induced by IRI and the concentration of those proteins increases during hypoxia and dysoxia. Activation of the HIF system leads to augmented transcription of specific genes in various types of affected cells, but may also augment apoptotic and inflammatory processes, thus aggravating gut injury. KEY POINTS: During intestinal ischaemia, mitochondrial oxygen uptake is reduced when cellular oxygen partial pressure decreases to below the threshold required to maintain normal oxidative metabolism. Upon reperfusion, intestinal hypoxia may persist because microcirculatory flow remains impaired and/or because available oxygen is consumed by enzymes, intestinal cells and neutrophils.

[CT imaging in the treatment of ventral hernias]

Ventral hernias are one of the most common problems in abdominal surgery. At the same time, clinical diagnosis of abdominal hernia is a straightforward issue amenable to surgical treatment in the absence of severe comorbidities. However, long-term follow-up revealed disappointing results regarding complication rates and incidence of postoperative recurrences. In this context, preoperative planning with control of comorbidities and complete visualization of hernia and its anatomical relationships with abdominal organs is important. Computed tomography (CT) offers the best opportunity to determine dimensions and location of hernial defect(s), diastasis recti and/or associated muscle atrophy, as well as loss of domain. This information is valuable to select the best surgical technique (open or minimally invasive), location and fixation of mesh, possible need for various separation techniques, botulinum toxin, preoperative pneumoperitoneum or reduction interventions on abdominal organs. Nevertheless, this issue remains peripheral to active surgical discussions focusing on intervention techniques, postoperative management, etc., since there is currently no clear communication between radiologists and surgeons in this area of surgery. This review is devoted to the role of CT in the treatment of ventral hernias.

Scanning the aged to minimize missed injury: An Eastern Association for the Surgery of Trauma multicenter study

BACKGROUND

Despite the high incidence of blunt trauma in older adults, there is a lack of evidence-based guidance for computed tomography (CT) imaging in this population. We aimed to identify an algorithm to guide use of a pan-scan (head/cervical spine [C-spine]/torso) or a selective scan (head/C-spine ± torso). We hypothesized that a patient's initial history and examination could be used to guide imaging.

METHODS

We prospectively studied blunt trauma patients 65 years or older at 18 Level I/II trauma centers. Patients presenting >24 hours after injury or who died upon arrival were excluded. We collected history and physical elements and final injury diagnoses. Injury diagnoses were categorized into CT body regions of head/C-spine or Torso (chest, abdomen/pelvis, and thoracolumbar spine). Using machine learning and regression modeling as well as a priori clinical algorithms based, we tested various decision rules against our data set. Our priority was to identify a simple rule, which could be applied at the bedside, maximizing sensitivity and negative predictive value (NPV) to minimize missed injuries.

RESULTS

We enrolled 5,498 patients with 3,082 injuries. Nearly half (n = 2,587 [47.1%]) had an injury within the defined CT body regions. No rule to guide a pan-scan could be identified with suitable sensitivity/NPV for clinical use. A clinical algorithm to identify patients for pan-scan, using a combination of physical examination findings and specific high-risk criteria, was identified and had a sensitivity of 0.94 and NPV of 0.86. This rule would have identified injuries in all but 90 patients (1.6%) and would theoretically spare 11.9% (655) of blunt trauma patients a torso CT.

CONCLUSION

Our findings advocate for head/C-spine CT in all geriatric patients with the addition of torso CT in the setting of positive clinical findings and high-risk criteria. Prospective validation of this rule could lead to streamlined diagnostic care of this growing trauma population.

LEVEL OF EVIDENCE

Diagnostic Tests or Criteria; Level II.

The role of rapid multiplex molecular syndromic panels in the clinical management of infections in critically ill patients: an experts-opinion document

Rapid multiplex molecular syndromic panels (RMMSP) (3 or more pathogens and time-to-results < 6 h) allow simultaneous detection of multiple pathogens and genotypic resistance markers. Their implementation has revolutionized the clinical landscape by significantly enhancing diagnostic accuracy and reducing time-to-results in different critical conditions. The current revision is a comprehensive but not systematic review of the literature. We conducted electronic searches of the PubMed, Medline, Embase, and Google Scholar databases to identify studies assessing the clinical performance of RMMSP in critically ill patients until July 30, 2024. A multidisciplinary group of 11 Spanish specialists developed clinical questions pertaining to the indications and limitations of these diagnostic tools in daily practice in different clinical scenarios. The topics covered included pneumonia, sepsis/septic shock, candidemia, meningitis/encephalitis, and off-label uses of these RMMSP. These tools reduced the time-to-diagnosis (and therefore the time-to-appropriate treatment), reduced inappropriate empiric treatment and the length of antibiotic therapy (which has a positive impact on antimicrobial stewardship and might be associated with lower in-hospital mortality), may reduce the length of hospital stay, which could potentially lead to cost savings. Despite their advantages, these RMMSP have limitations that should be known, including limited availability, missed diagnoses if the causative agent or resistance determinants are not included in the panel, false positives, and codetections. Overall, the implementation of RMMSP represents a significant advancement in infectious disease diagnostics, enabling more precise and timely interventions. This document addresses relevant issues related to the use of RMMSP on different critically ill patient profiles, to standardize procedures, assist in making management decisions and help specialists to obtain optimal outcomes.

Management of heparin-induced thrombocytopenia during extracorporeal membrane oxygenation support: a case of neutropenia caused by argatroban anticoagulation

We present the case of a man in his 70s admitted to the intensive care unit (ICU) after mitral valve replacement and coronary artery bypass graft surgery requiring extracorporeal membrane oxygenation support due to haemodynamic instability. He received anticoagulation therapy with heparin sodium and, after 5 days, the patient presented with thrombocytopenia and deep venous thrombosis. Heparin-induced thrombocytopenia was suspected based on a positive 4T score and confirmed by antiplatelet factor 4/heparin antibodies, so argatroban was initiated as an alternative anticoagulation therapy. In the following days the patient developed severe neutropenia requiring discontinuation of argatroban and the administration of granulocyte colony-stimulating factor. According to the Naranjo Adverse Drug Reaction Probability Scale, this event would be classified as a 'probable' argatroban-related adverse event. Argatroban should be conisdered as a possible cause of neutropenia and appropriate interventions need to be implemented due to the gravity of this adverse event in the ICU.

Clopidogrel-induced thrombotic microangiopathy: a case report

Thrombotic microangiopathy is a serious condition that can be precipitated by exposure to certain medications. Although rare, it is life threatening and requires a high index of clinical suspicion, appropriate laboratory testing and immediate cessation of the offending agent. We present a case of a 75-year-old man with a history of ischaemic heart disease treated with clopidogrel and aspirin. One month after initiating the treatment he developed microangiopathic haemolytic anaemia and thrombocytopenia. Extensive clinical and laboratory investigations suggested thrombotic microangiopathy secondary to clopidogrel. The drug was immediately discontinued and treatment with intravenous corticosteroids was started. Within a week the patient's laboratory parameters normalised, indicating successful recovery. This case highlights the role of early detection and immediate discontinuation of suspected medication in the effective management of clopidogrel-induced thrombotic microangiopathy. Healthcare professionals should consider drug-induced thrombotic microangiopathy as a possible diagnosis in patients receiving clopidogrel who present with thrombocytopenia and microangiopathic haemolytic anaemia.

ECMO for bridging lung transplantation

BACKGROUND

With the shift in donor lung allocation from blood type and waiting order to the use of the lung allocation score (LAS) system, there are increasingly more cases of ECMO bridging lung transplantation. However, there are still some problems in case selection, implementation, and management.

METHODS

We analyzed and summarized a series of data on ECMO bridging lung transplantation through an extensive literature review.

RESULTS

The improvement of the lung transplant allocation system and the progress of ECMO technology have made the ECMO bridge to lung transplant more widely used in clinical practice. The selection of bridge patients is a crucial link in the success of transplantation, and accurate assessment of the patient before transplantation is necessary. The advantages and disadvantages of different bridge strategies exist, and the appropriate bridge strategy should be selected based on the patient's situation. Bleeding and thrombosis complications often occur during ECMO circulation, and there is currently no optimal anticoagulation strategy. The predictive score for bridge post-outcome is still subject to certain limitations.

CONCLUSIONS

ECMO bridging lung transplantation is suitable for patients waiting for lung transplantation when other respiratory support is ineffective or when hemodynamic instability occurs the disease is severe and the donor organ is easily obtainable. Patients aged 65 years or older, or have reversible multiple organ dysfunction should not be included as contraindications for ECMO bridging lung transplantation.

Use of extracorporeal blood purification therapies in sepsis: the current paradigm, available evidence, and future perspectives

BACKGROUND

Sepsis is the result of a dysregulated immune response to infection and is associated with acute organ dysfunction. The syndrome's complexity is contingent upon the underlying pathology and individual patient characteristics, including their immune response. The involvement of multiple organs and physiological functions adds complexity, with "organ cross-talk" emerging as a pivotal pathophysiological and clinical aspect. This narrative review to evaluate the rationale and available clinical evidence supporting the use of extracorporeal blood purification therapies as adjunctive therapy in patients with sepsis and septic shock.

MAIN BODY

A search of the PubMed, Embase, Web of Science and Scopus databases for relevant literature from August 2002 to May 2024 has been conducted. The search was performed using the terms: 1) "blood purification" or "hemadsorption" or "plasma exchange" AND 2) "sepsis" or "septic shock". Therefore the authors have focused our discussion on several key areas such as conducting well-designed trials, developing more personalized protocols, ensuring optimal management and monitoring.

CONCLUSIONS

Given the heterogeneity of patients with sepsis, conducting traditional randomized clinical trials in this domain can be a daunting task. However, statistical techniques such as Bayesian methods, propensity score analysis, and emulated clinical trials using clinical databases hold promise for enhancing comparability between the study groups. Indeed, to comprehend the clinical efficacy of extracorporeal blood purification techniques in patients with sepsis, it is imperative to assemble homogeneous groups of patients receiving uniform treatments. Clinical strategies should be individualized, signaling the end of the "one size fits all" approach in sepsis therapy and the need for personalized treatments.

Association between alcohol use disorder and the incidence of delirium in the intensive care unit: a retrospective cohort study using propensity score matching

BACKGROUND

Although alcohol consumption is considered one of the risk factors for delirium in intensive care unit (ICU) patients, quantitative research on the association between alcohol use disorder (AUD) and the development of delirium in the ICU remains relatively scarce.

METHODS

This retrospective cohort study was conducted using the Medical Information Mart for Intensive Care-IV database, including all patients admitted to the ICU for the first time and underwent delirium assessment. Patients were divided into AUD and non-AUD groups, with the primary outcome being the occurrence of ICU delirium. Propensity score matching (PSM) was used to balance baseline characteristics between the two groups. The association between AUD and the occurrence of ICU delirium was evaluated using Cox proportional hazards and competing risk models, with sensitivity and subgroup analyses to assess the stability of the results.

RESULTS

A total of 35,053 patients were included, with 3,455 (9.9%) in the AUD group. The incidence of ICU delirium and ICU mortality were significantly higher in the AUD group compared to the non-AUD group, with a longer median ICU stay. Multivariable Cox regression analysis, adjusting for all covariates, revealed a significant association between AUD and increased risk of ICU delirium (HR 1.59, 95% CI 1.50-1.69, P < 0.01). After PSM, multivariable Cox regression analysis showed consistent results (HR 1.52, 95% CI 1.41-1.65, P < 0.01), and these results remained consistent after performing competitive risk analysis.

CONCLUSIONS

We found a significant correlation between AUD and the incidence of delirium in the ICU, highlighting the importance of assessing and managing the risk of delirium in patients with AUD in the ICU.

CLINICAL TRIAL NUMBER

Not applicable.

Spiritual Care Interventions for Adult Patients in Intensive Care Units: A Scoping Review Protocol

Caring for patients in intensive care units (ICUs) requires healthcare workers to recognize the importance of a spiritual care approach in these settings. Moving toward a holistic and patient-centered care model that incorporates spiritual care is essential for enhancing patients' healing process. The disease-centered approach of ICU and the perceived deficit of spiritual care highlight the need to add knowledge on integrating spiritual care interventions into daily ICU practices. The aim of this scoping review will be to develop a comprehensive overview of the characteristics of spiritual care interventions for adult patients in ICU according to JBI methodology and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines. The inclusion criteria will be informed by the types of participants, concept and context, and types of evidence sources. Quantitative, qualitative and mixed methods studies, editorials, opinion papers and gray literature will be included. Databases such as PubMed (National Library of Medicine), CINAHL, Academic Search Complete, Psychology and Behavioral Sciences Collection, APA PsycINFO, Cochrane Central Register of Controlled Trials (via EBSCOhost), Scopus and Web of Science Core Collection will be searched. No date limit will be set. Titles and abstracts that meet the inclusion criteria, full texts of eligible studies and reference lists of all selected sources will be screened by 2 independent reviewers. Data will be extracted using customized tools, presented in diagrammatic or tabular format and summarized in a final narrative synthesis report. This research represents the first effort to develop a comprehensive overview of the characteristics of spiritual care interventions exclusively targeting adult patients in ICU settings. The findings will offer a thorough review of these interventions, including their main attributes, providers, resources, associated outcomes and assessment tools. Consequently, this knowledge can enhance the spiritual dimension of patient-centered care in the ICU, thereby promoting a shift from the traditional biomedical model to a more holistic perspective and establishing a new standard in critical care.

A Comprehensive Review of Catheter-Related Thrombosis

Catheter-related thrombosis (CRT) is a frequent and potentially serious complication associated with the widespread use of intravascular devices such as central venous catheters, including peripherally inserted central catheters and implantable port systems, pacemakers or implantable cardioverter-defibrillators. Although CRT management has been informed by guidelines extrapolated from lower extremity deep vein thrombosis (DVT), unique challenges remain due to the distinct anatomical, pathophysiological, and clinical characteristics of upper extremity DVT. Risk factors for CRT are multifactorial, encompassing patient-related characteristics such as cancer, prior venous thromboembolism, and infection, as well as catheter-specific factors like device type, lumens, and insertion site. The diagnosis of CRT relies primarily on ultrasonography; however, computed tomography angiography and magnetic resonance imaging play a complementary role, particularly in anatomically challenging cases or when complications such as pulmonary embolism or superior vena cava syndrome are suspected. Treatment strategies for CRT include anticoagulation, catheter removal when feasible, and, in select cases, local thrombolysis or catheter-directed interventions. Anticoagulation remains the cornerstone of therapy, with direct oral anticoagulants increasingly favored due to their safety profile and efficacy. This article provides a detailed review of CRT, focusing on clinical features, diagnostic methods, and treatment strategies while addressing specific challenges in managing pacemaker and hemodialysis catheter-related thrombosis.

Impact of Thrombomodulin Polymorphism -33G>A on Acute Myocardial Infarction Risk and Circulating Inflammatory Markers

BACKGROUND

There is increasing evidence that thrombomodulin (THBD) polymorphisms, along with inflammatory markers [i.e., C-reactive protein (CRP), fibrinogen, albumin], may increase the risk of acute myocardial infarction (AMI). The aim of the study was to investigate the role of the THBD -33G>A polymorphism (rs1042579) as a marker of AMI risk and to correlate it with serum levels of inflammatory markers.

METHODS

Case-control study of 277 AMI patients and 329 healthy controls. A binary logistic regression analysis was performed to evaluate the association between the parameters studied and AMI risk.

RESULTS

The frequencies of genotypes AA, GA, and GG of the THBD -33G>A polymorphism were 31.4%, 45.5%, and 23.1% in patients and 21.6%, 44.1%, and 34.3% in controls. A significant association was found between the AA genotype of the THBD -33G>A polymorphism (AA: OR = 2.011, 95% CI 1.561-3.074, P < .001) or A allele (A: OR = 1.725, 95% CI 1.493-2.510, P < .001) and AMI risk. A backward stepwise logistic regression method combining AMI status as the dependent variable and conventional risk factors (age, smoking, arterial hypertension (HTA), diabetes, dyslipidemia, CRP, albumin, fibrinogen, serum angiotensin converting enzyme (ACE) activity, serum malondialdehyde, conjugated dienes, glutathione peroxidase, cardiac troponin-I (cTnI) and THBD AA genotype) as independent variables showed that the most predictive risk factors for AMI were smoking, HTA, albumin, fibrinogen, CRP, ACE activity, cTnI, and the THBD AA-genotype with odds ratios of 2.942, 2.203, 2.352, 1.323, 1.652, 1.014, 2.105, and 3.781 respectively. The AA genotype was associated with increased diastolic blood pressure, CRP, ACE activity, and albumin levels.

CONCLUSIONS

The study shows that the THBD -33G>A polymorphism should be included in the stratification of AMI risk.

Ultrasonographic modeling of lung and diaphragm mechanics: clinical trial of a novel non-invasive method to evaluate pre-operative pulmonary function

Background

Pre-operative pulmonary function testing (PFT) plays a key role in predicting postoperative complications or functional impairment. However, PFT requires the subject and examiner to cooperate and the results are influenced by both technical and personal factors. In contrast, the use of ultrasound (US) for structural and functional assessments of the lungs and diaphragm is on the rise, as it requires minimal patient cooperation. Dyspnea is mainly caused by lung or pleural lesions but may also be caused by weak respiratory muscles. As the diaphragm is a primary respiratory muscle, combining lung ultrasonography (LUS) with diaphragm ultrasound (DUS) may enable a more comprehensive assessement of pulmonary function. This study aims to introduce a novel approach for assessing pulmonary function using a mathematical model based on LUS and DUS.

Methods

This prospective study was performed at the First Affiliated Hospital of Nanchang University between June 2021 and December 2021, 208 patients were recruited and underwent PFT, LUS, and DUS examinations. An experienced physician, blinded to the clinical history and PFT results, performed LUS and DUS and explored the correlations between a mathematical model (ultrasonographic modeling score (U-score)) using LUS combined with DUS and pulmonary function parameters. Univariate, multivariate, and logistic regression analyses were also performed.

Results

According to the univariate and multivariable analysis, diaphragm thickness fraction in deep breathing (D-DTF) (odds ratio (OR), 0.88; 95% confidence interval (CI) [0.83-0.94]; P < 0.001), and LUS score (OR, 1.44; 95% CI [1.16-1.80]; P < 0.001) were each independently associated with pulmonary function. According to the logistics equation, a U-score of -0.126 × D-DTF + 0.368 × LUS score was produced. The U-score showed a more significant negative correlation with forced expiratory volume in the first second/forced vital capacity (FEV1/FVC) (r = -0.605, P < 0.001) than the LUS or DUS indices alone. The U-score (area under the curve (AUC) = 0.971) was greater than the other indices for assessing pulmonary function.

Conclusions

With validation, the U-score through both lung and diaphragm ultrasound measurements may assist in estimating pulmonary function. This approach facilitates the assessment of pulmonary function in patients who may be unable to reliably participate in PFT.

Risk factors of healthcare-associated infection among healthcare workers in intensive care units: A multicenter cross-sectional study

BACKGROUND

Healthcare-associated infections (HAIs) are a major global health threat, leading to higher morbidity and mortality, longer hospital stays, and increased healthcare expenses. Intensive care units (ICUs) present a particularly high risk of developing HAIs. This study aims to examine the risk factors of HAIs among healthcare workers (HCWs) in the ICUs of selected public hospitals.

METHODS

We employed a cross-sectional design using an online survey. Respondents were randomly selected from seven large public hospitals located in different areas of Riyadh, the capital city of Saudi Arabia. Data collection was conducted between November 1st to 15th, 2023. Logistic regression analysis was employed to examine previous exposure to HAIs as the response variable and selected predictors.

RESULTS

A total of 600 HCWs participated in the study (response rate 88.2%). Among the study HCWs, 75.1% were female, with nurses making up 50% of the sample. Of the respondents, 78% had at least a year's experience, 71% had applied infection prevention and control (IPC) training from the infection control department, and 93% reported they had good knowledge about infection control. The level of knowledge of IPC (OR = 0.9, p < 0.05) and applied IPC training (0.1, p < 0.001) were significantly associated with a lower risk of HAIs. Additionally, a higher risk of HAIs was associated with HCWs years of clinical experience (p < 0.001).

CONCLUSION

Overall, the findings indicated that HCWs who have poor knowledge of IPC, who reported no previous IPC applied training, and who have more years of clinical work experience have a greater risk of HAIs. Thus, legislators and Health officials should prioritize the prevention of infections linked to healthcare, paying particular attention to tailored and applied IPC initiatives.

Copper-Based Nanoparticles for Effective Treatment Against Sepsis-Induced Lung Injury in Mice Model

Introduction

Lung injury, a common complication of sepsis, arises from elevated reactive oxygen species (ROS), mitochondrial dysfunction, and cell death driven by inflammation. In this study, a novel class of ultrasmall nanoparticles (Cu4.5O USNPs) was developed to address sepsis-induced lung injury (SILI).

Methods

The synthesized nanoparticles were thoroughly characterized to assess their properties. In vitro experiments were conducted to determine the biologically effective concentration and elucidate the anti-inflammatory mechanism of action. These findings were further supported by in vivo studies, showcasing the material's efficacy in mitigating SILI.

Results

The Cu4.5O USNPs demonstrated remarkable scavenging capabilities for hydrogen peroxide (H2O2), superoxide anions (O2 -), and hydroxyl radicals (·OH), attributed to their catalase (CAT)- and superoxide dismutase (SOD)-like activities. Additionally, the nanoparticles exhibited strong anti-inflammatory effects, preserved mitochondrial homeostasis through potent ROS scavenging, and significantly reduced cell death. In vivo studies on mice further validated their protective role against SILI.

The conclusion

This study highlights the therapeutic potential of Cu4.5O USNPs in treating sepsis-induced lung injury by effectively scavenging ROS and reducing cell death. These findings provide compelling evidence for the future use of copper-based nanoparticles as antioxidant therapeutics.

Hemodynamic Management with Vasopressin for Cardiovascular Surgery

Background and Objectives: Vasopressin increases blood pressure through aquaporin-2-mediated water retention and is useful for managing hemodynamics after surgery. However, even after decades of study, clear clinical guidelines on doses and ideal use cases after cardiovascular surgery remain unclear. Here, the existing literature is synthesized on vasopressin use for cardiac surgeries and coupled with real-world clinical experience to outline a clearer clinical path for vasopressin use. Materials and Methods: Literature from 1966 to the present was searched, and information on surgical outcomes for cardiovascular surgery was extracted. Clinicians from the University of Tsukuba with extensive vasopressin experience in pediatric cardiovascular patients were consulted for general use guidelines. Results: Vasopressin response after cardiovascular surgery is multifaceted, and low-power trials, plus conflicting study reports, generally render it as a secondary choice behind norepinephrine. Clinical experience indicates that low doses of 0.2-0.3 mU/kg/min with constant blood pressure and oxygen monitoring for response are required. Although sole use is not recommended, vasopressin may aid in controlling hemodynamics when given with other volemic or osmolal drugs. Conclusions: Vasopressin may work in a select population of first-line non-responders, but relevant response factors remain unanalyzed and clear guidelines for use remain unestablished. Future, large-scale studies are needed to delineate temporal and demographic characteristics that affect response to vasopressin for the purpose of managing post-surgical capillary leakage and hemodynamics.

Upper Arm Deep Vein Thrombosis in a Patient with Active Lupus

Upper extremity deep vein thrombosis (UEDVT) is relatively rare, and much less as an initial presentation of systemic lupus erythematosus (SLE). Primary UEDVT should be considered in individuals with unilateral arm swelling where the brachial, axillary, and subclavian veins are frequently involved. SLE is a chronic autoimmune disease that predominantly affects women of childbearing age and of African descent. Patients present with clinical features ranging from arthritis and arthralgias (over 90% of patients with SLE) to life-threatening hematologic, or central nervous system involvement. Individuals have an increased risk of arterial and/or venous thrombosis where the most important risk factor is the presence of antiphospholipid antibodies. Even within this condition, thrombotic events are typically seen in the legs, and UEDVT remains an unusual presentation. Here, we present a case of a 36-year-old female of African descent with a recent medical history of small joint arthralgia and vaginal bleeding due to uterine fibroids, for which she was prescribed a short course of prednisolone and norethisterone, respectively. She presented with a 2-week history of unilateral swelling in the left arm. Doppler ultrasound and later computed tomography scan with contrast indicated left UEDVT. Further investigations throughout her admission led to the diagnosis of SLE, while antiphospholipid syndrome - a common contributor to thrombosis in SLE - was notably ruled out. The patient was initiated on anticoagulants. The patient went on to later rapidly develop lupus nephritis and started on high-dose prednisolone. Given the high risk of bleeding, the decision to postpone the kidney biopsy was taken. There is limited data available about UEDVT when compared to lower extremity DVT and even fewer studies on SLE patients with thrombosis in the absence of antiphospholipid syndrome. Keeping this in mind, clinicians need to recognize idiopathic UEDVT as a potential early sign of SLE and maintain a high level of suspicion.

LEARNING POINTS

To highlight the possibility of idiopathic upper extremity deep vein thrombosis (UEDVT) in spontaneous unilateral arm swelling.Idiopathic UEDVT might indicate a serious underlying autoimmune condition as SLE in this case (in the absence of antiphospholipid syndrome), that requires intensive thorough investigation by a multidisciplinary team.Initial treatment of both UEDVT and lupus nephritis with standard dose anticoagulants and steroids might be the proper initial management, whereas kidney biopsy might not be necessary as the risk of bleeding is high while on anticoagulants.

Successful Treatment of Unilateral Pulmonary Edema as Minimally Invasive Mitral Valve Surgery Complication-Case Presentation

Background/Objectives: In recent decades, the advantages of minimizing surgical trauma have led to the development of minimally invasive surgical procedures. While the benefits often outweigh the risks, several challenges are encountered that are not present in conventional surgical approaches. Unilateral pulmonary edema (UPE) after mitral interventions performed through a right-sided approach is a rare but potentially life-threatening event. Methods: We present the case of a 49-year-old patient who underwent endoscopic mitral valve repair. Immediately following ICU admission, the patient's oxygen saturation suddenly dropped, and serous discharge was exteriorized from the endotracheal tube, with a thoracic X-ray revealing right-sided unilateral pulmonary edema. Results: The therapeutical course was complex. The patient developed hemodynamic instability, leading to cardiac arrest, which required cardiopulmonary resuscitation and the initiation of peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO). The endotracheal cannula was replaced with a right-sided double-lumen cannula, and the patient was placed on two ventilators operating independently. The patient was weaned off extracorporeal membrane oxygenation (ECMO) on the fifth day and extubated on the sixth postoperative day. Conclusions: We successfully treated this patient using ECMO and independent lung ventilation. Several cases have been described in the literature, but the pathogenesis and risk factors of UPE remain unclear. Management depends on the severity of UPE, but a deeper understanding of its underlying mechanisms could provide cardiac surgeons with enhanced strategies for preventing UPE and implementing timely interventions.

Traumatic brain injury: Symptoms to systems in the 21st century

Severe traumatic brain injury (TBI) is a devastating injury with a mortality of ∼ 25-30 %. Despite decades of high-quality research, no drug therapy has reduced mortality. Why is this so? We argue two contributing factors for the lack of effective drug therapies include the use of specific-pathogen free (SPF) animals for translational research and the flawed practice of single-nodal targeting for drug design. A revolution is required to better understand how the whole body responds to TBI, identify new markers of its progression, and discover new system-acting drugs to treat it. In this review, we present a brief history of TBI, discuss its system's pathophysiology and propose a new research strategy for the 21st century. TBI progression develops from injury signals radiating from the primary impact, which can cause local ischemia, hemorrhage, excitotoxicity, cellular depolarization, immune dysfunction, sympathetic hyperactivity, blood-brain barrier breach, coagulopathy and whole-body dysfunction. Metabolic reprograming of immune cells drives neuroinflammation and secondary injury processes. We propose if sympathetic hyperactivity and immune cell activation can be corrected early, cardiovascular function and endothelial-glycocalyx-mitochondrial coupling can be restored, and secondary injury minimized with improved patient outcomes. The therapeutic goal is to switch the injury phenotype to a healing phenotype by restoring homeostasis and maintaining sufficient tissue O2 delivery. We have been developing a small-volume fluid therapy comprising adenosine, lidocaine and magnesium (ALM) to treat TBI and have shown that it blunts the CNS-stress response, supports cardiovascular function and reduces secondary injury. Future research will investigate its suitability for human translation.

Pulmonary consequences of experimentally induced stroke: differences between global and focal cerebral ischemia

Introduction

Cerebral ischemia leads to multiple organ dysfunctions, with the lungs among the most severely affected. Although adverse pulmonary consequences contribute significantly to reduced life expectancy after stroke, the impact of global or focal cerebral ischemia on respiratory mechanical parameters remains poorly understood.

Methods

Rats were randomly assigned to undergo surgery to induce permanent global cerebral ischemia (2VO) or focal cerebral ischemia (MCAO), or to receive a sham operation (SHAM). Three days later, end-expiratory lung volume, airway and respiratory tissue mechanics were measured at positive end-expiratory pressure (PEEP) levels of 0, 3 and 6 cmH2O. Bronchial responsiveness to methacholine, lung cytokine levels, wet-to-dry ratio, blood gas parameters and cerebral stroke markers were also evaluated.

Results

Global and focal cerebral ischemia had no significant effect on end-expiratory lung volume, bronchial responsiveness, and arterial blood gas levels. No change in respiratory mechanics and inflammatory response was evident after 2VO. Conversely, MCAO decreased airway resistance at PEEP 0, deteriorated respiratory tissue damping and elastance at all PEEP levels, and elevated Hct and Hgb. MCAO also caused lung edema and augmented IL-1β and TNF-α in the lung tissue without affecting IL-6 and IL-8 levels.

Discussion

Our findings suggest that global cerebral ischemia has no major pulmonary consequences. However, deteriorations in the respiratory tissue mechanics develop after permanent focal ischemia due to pulmonary edema formation, hemoconcentration and cytokine production. This respiratory mechanical defect can compromise lung distension at all PEEP levels, which warrants consideration in optimizing mechanical ventilation.

A machine learning-based risk score for prediction of mechanical ventilation in children with dengue shock syndrome: A retrospective cohort study

BACKGROUND

Patients with severe dengue who develop severe respiratory failure requiring mechanical ventilation (MV) support have significantly increased mortality rates. This study aimed to develop a robust machine learning-based risk score to predict the need for MV in children with dengue shock syndrome (DSS) who developed acute respiratory failure.

METHODS

This single-institution retrospective study was conducted at a tertiary pediatric hospital in Vietnam between 2013 and 2022. The primary outcome was severe respiratory failure requiring MV in the children with DSS. Key covariables were predetermined by the LASSO method, literature review, and clinical expertise, including age (< 5 years), female patients, early onset day of DSS (≤ day 4), large cumulative fluid infusion, higher colloid-to-crystalloid fluid infusion ratio, severe bleeding, severe transaminitis, low platelet counts (< 20 x 109/L), elevated hematocrit, and high vasoactive-inotropic score. These covariables were analyzed using supervised models, including Logistic Regression (LR), Random Forest (RF), Support Vector Machine (SVM), k-Nearest Neighbor (KNN), and eXtreme Gradient Boosting (XGBoost). Shapley Additive Explanations (SHAP) analysis was used to assess feature contribution.

RESULTS

A total of 1,278 patients were included, with a median patient age of 8.1 years (IQR: 5.4-10.7). Among them, 170 patients (13.3%) with DSS required mechanical ventilation. A significantly higher fatality rate was observed in the MV group than that in the non-MV group (22.4% vs. 0.1%). The RF and SVM models showed the highest model discrimination. The SHAP model explained the significant predictors. Internal validation of the predictive model showed high consistency between the predicted and observed data, with a good slope calibration in training (test) sets 1.0 (0.934), and a low Brier score of 0.04. Complete-case analysis was used to construct the risk score.

CONCLUSIONS

We developed a robust machine learning-based risk score to estimate the need for MV in hospitalized children with DSS.

Assessment of the correlation between the Vittel criteria and the ISS score: A novel approach to pre-hospital severe trauma patient's triage

Introduction-Aim: Validated triage tools such as the Vittel criteria are essential to improve the care of trauma patients. The aim of this study was to evaluate the correlation between the Vittel triage criteria and the Injury Severity Score (ISS) to improve the accuracy of pre-hospital triage.

METHODS

We conducted a longitudinal study of all trauma patients transported by EMS over a two-year period (November 2021- November 2023). Vittel and (ISS) scores were calculated on admission. Predictive Vittel criteria were defined by independent risk factors for ISS>15 using a multiple logistic regression model with p-value < 0.05 and/or sensitivity (se)>50%, with positive Youden index (Yi).

RESULTS

A total of 461 trauma patients were transported by EMS during the study period were included. The sex ratio was 5.3 and road traffic accidents accounted for 77.2%. An ISS>15 was found in 41% of participants, 25% required ICU admission and 23.9% died within 30 days. Using the above selection criteria, we identified seven key predictive criteria (OR CI 95%, se%, Yi) Glasgow coma scale<13(3.16 [1.91 5.24],44,0.25); fall>6 m(4.031[1.61-10.08],10,0.07); severe burn(23.89[10.21-55.93],6,0.02); Pelvic fracture (4.93 [1.19-20.32], 28, 0.25),suspected spinal cord injury(6.89 [2.79-16.96], 6, 0.05); Fluid resuscitation>1000 ml(-, 60.0. 11); Catecholamine (2.02 [1.09-3.75],51.0.27). Physiological variables (se 30%, Yi 0.16) and pre-hospital resuscitation(se 46%, Yi 0.18) were among the most relevant categories for predicting severity, similar to the full Vittel score.

CONCLUSION

Seven criteria were associated with severe trauma (ISS score >15). Physiological variables and pre-hospital resuscitation were significant categories that may help to predict the severity of trauma and its impact on patients.

Orientia, Rickettsia, and the microbiome in rodent attached chiggers in North Carolina, USA

Chiggers are larval mites that pose a significant health risk globally via the spread of scrub typhus. However, fundamental studies into the bacterial microbiome in North America have never been considered. In this investigation, chiggers were collected in the wild from two locally common rodent host species (i.e., Sigmodon hispidus and Peromyscus leucopus) in three different ecoregions of North Carolina (NC), United States to investigate the composition of their bacterial communities, including potential pathogens. DNA was extracted from the chiggers, and the V3-V4 regions of the bacterial 16S rRNA gene were sequenced using next-generation sequencing (NGS). Alpha diversity metrics revealed significant differences in bacterial diversity among different collection counties. Beta diversity metrics also revealed that bacterial communities across counties were significantly different, suggesting changes in the microbiome as the environment changed. Specifically, we saw that the two western NC collection counties had similar bacterial composition as did the two eastern collection counties. In addition, we found that the chigger microbiome bacterial diversity and composition differed between rodent host species. The 16S rRNA sequence reads were assigned to 64 phyla, 106 orders, 199 families, and 359 genera. The major bacterial phylum was Actinobacteria. The most abundant species were in the genera Corynebacterium, Propionibacterium, class ZB2, and Methylobacterium. Sequences derived from potential pathogens within the genera Orientia and Rickettsia were also detected. Our findings provide the first insights into the ecology of chigger microbiomes in the US. Further research is required to determine if the potential pathogens found detected in chiggers are a threat to humans and wildlife.

The Urban-Rural Divide in Neurocritical Care in Low-Income and Middle-Income Countries

The term "urban-rural divide" encompasses several dimensions and has remained an important concern for any country. The economic disparity; lack of infrastructure; dearth of medical specialists; limited opportunities to education, training, and health care; lower level of sanitation; and isolating effect of geographical location deepens this gap, especially in low-income and middle-income countries (LMICs). This article gives an overview of the rural-urban differences in terms of facilities related to neurocritical care (NCC) in LMICs. Issues related to common clinical conditions such as stroke, traumatic brain injury, myasthenia gravis, epilepsy, tubercular meningitis, and tracheostomy are also discussed. To facilitate delivery of NCC in resource-limited settings, proposed strategies include strengthening preventive measures, focusing on basics, having a multidisciplinary approach, promoting training and education, and conducting cost-effective research and collaborative efforts. The rural areas of LMICs bear the maximum impact because of their limited access to preventive health services, high incidence of acquired brain injury, inability to have timely management of neurological emergencies, and scarcity of specialist services in a resource-deprived health center. An increase in the health budget allocation for rural areas, NCC education and training of the workforce, and provision of telemedicine services for rapid diagnosis, management, and neurorehabilitation are some of the steps that can be quite helpful.

Multidisciplinary Management of Complex Trauma and Burn Injuries: A Case Series of Challenging Clinical Scenarios

Trauma and burn injuries often present with multiple complications, necessitating a coordinated, multidisciplinary approach to management. This case series reviews the outcomes and challenges of treating high-risk trauma and burn patients, with a focus on complex polytrauma, alcohol withdrawal, high-voltage electrical injuries, and lightning strikes. Each case underscores the importance of early intervention, multidisciplinary team involvement, and individualized treatment protocols for improving patient outcomes in critically injured burn victims.

A Rare Case of Erythromycin-Induced Rhabdomyolysis

Rhabdomyolysis (RML) arises from the breakdown of muscle tissue, leading to the release of intracellular components into the bloodstream and potentially causing multi-organ failure. Multiple drugs have been reported to cause RML. We present here a rare instance of erythromycin-triggered RML in a patient who was not on any other potential RML-inducing medications. A 25-year-old male presented to the ED complaining of a tingling sensation and increased dyspnea with muscle aches. He took erythromycin over the counter for two days before. On presentation, diffuse muscle tenderness was found, and the vitals showed tachycardia and tachypnea. Labs showed elevated creatinine, peaking at 10.1, and elevated creatine kinase (CK) peaking at 1.2 million. He was treated in ICU with aggressive fluid resuscitation. Then he required dialysis due to fluid overload and not responding to diuretics. Extensive workup failed to find a cause for RML. This represents only the second documented instance of erythromycin-induced RML in a patient who is not concurrently using any other myotoxic medications. Before attributing the patient's condition to the erythromycin he was taking, it was essential to rule out the typical triggers of RML. Every physician must be familiar with the symptoms and prevalent triggers of RML.

The Reality of Evaluating Urine Spot Sodium and Urine Spot Sodium Creatinine Ratio in Furosemide Stress Test as a New Biomarker in Diagnosing Progressive AKI in Critically Ill

How to cite this article: Chatterjee R, Gupta L. The Reality of Evaluating Urine Spot Sodium and Urine Spot Sodium Creatinine Ratio in Furosemide Stress Test as a New Biomarker in Diagnosing Progressive AKI in Critically Ill. Indian J Crit Care Med 2024;28(12):1089-1090.

Treatment of cerebral venous thrombosis: a review

Cerebral venous thrombosis (CVT) is an uncommon cause of stroke. COVID-19 infection and vaccination have been associated with CVT. Fibrinolysis and mechanical thrombectomy may play an emerging role in management. We conducted a literature review summarizing current evidence on use of antiplatelets, anticoagulants, thrombolysis, and mechanical thrombectomy for the management of CVT and COVID-19 related CVT. This was achieved through a review of MEDLINE, PubMed, and Cochrane Reviews databases, performed using the search terms CVT AND "antiplatelets' aspirin", "ticagrelor", "clopidogrel", "eptifibatide", "Low-molecular-weight-heparin (LMWH)", "Unfractionated heparin (UH)", "warfarin", "DOACs", "rivaroxaban", "apixaban", "dabigatran", "fibrinolysis", "intra-sinus thrombolysis", "mechanical thrombectomy", and "craniectomy". We found that LMWH and UH are safe and effective for the management of acute CVT and should be considered first line. Warfarin may be used in the sub-acute phase for secondary prevention but has weak evidence. DOACs are potentially a safe warfarin alternative, but only warfarin is currently recommended in international guidelines. Antiplatelets show little evidence for the prevention or management of CVT, but studies are currently limited. COVID-19 related CVT is treated similarly to non-COVID-19 CVT; however, vaccine-related CVT is a newly recognised disease with a different pathophysiology and is treated with a combination of non-heparin anticoagulants, immunotherapy, and steroids. Decompressive craniectomy may be used to reduce intracranial pressure in life-threatening cases. There is a small body of evidence for endovascular therapy in complex cases but should be reserved for complex cases in specialist centres. This paper is of relevance to clinical practice since the safe and effective management of CVT is important to reduce the risk of disability.

Treatment of acute kidney injury with continuous renal replacement therapy and cytokine adsorber (CytoSorb®) in critically ill patients with COVID-19

INTRODUCTION

This retrospective study aimed to evaluate the 30 and 60-day survival of critically ill patients with COVID-19 and AKI.

METHODS

Inflammatory and biochemical biomarkers, length of intensive care unit (ICU) stay and mortality at Day 30 and Day 60 after ICU admission were analyzed. A total of 44 patients treated with continuous renal replacement therapy (CRRT) with cytokine adsorber (CA group) were compared to 58 patients treated with CRRT alone (non-CA group).

RESULTS

Patients in CA group were younger, had better preserved kidney function prior to the beginning of CRRT and had higher levels of interleukin-6. There were no statistically significant differences in their comorbidities and in other measured biomarkers between the two groups. The number of patients who died 60 days after ICU admission was statistically significantly higher in non-CA group (p = 0.029).

CONCLUSION

Treatment with CRRT and cytokine adsorber may have positively influenced 60-day survival in our COVID-19 ICU patients with AKI.