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Care of the critically injured burn patient presents unique challenges to the intensivist. Certified burn centers are rare and geographically sparse, necessitating that much of the initial management of patients with severe burn injuries must happen in the pre-burn center setting. Severe burn injuries often lead to a wide range of complications that extend beyond the loss of skin integrity and require specialized care. As such, medical intensivists are often called on to stabilize these critically injured patients. This focused review outlines the clinical care of these medically complex patients, including airway management, postburn complications, volume resuscitation, nutrition, and end-of-life care.

To investigate the proximate and Aflatoxin B1 analysis in Chrozophora Tinctoria leaves were shade dried in the lab. The proximate composition of leaves was analyzed by standard methods. Mineral contents in this plant were analyzed by using atomic absorption spectrophotometer. The result revealed that Chrozophora Tinctoria leaves contained 86.68% dry matter, 9.80% moisture, 10.01% ash, 21.05% crude protein, Aflatoxin 14%, crude fibers, 14.05% carbohydrate, 44.87% crude fats and energy (243.65 kcal/100g). The analysis of Chrozophora Tinctoria revealed that this plant contains high amount of mycotoxin The type of mycotoxin in present in thise plant is known as Aflatoxin B1. Aflatoxin caused by high doses in short intervals or low doses in high intervals 1961 caused the death of over 100000 Turkey poults. Naturally produesd aflatoxins-B1,B2,G1,G2. Chrozophora Tinctoria also contained a high amount of aflatoxin (ppb). Aflatoxin a various poisous carcinogens and mutagens that are produeced by certain molds particularly aspergillus species the fungi grow in soil, decaying vegetation and various staple foodstuffs and commodities such as hay, sweetcorn, wheat ,millet, sorghum, and various species.This plant contains a huge amount of carbohydrates, and a good source of proteins and fibers.

Background Esophagectomy is associated with postoperative delirium, but its pathophysiology is not well defined. We conducted this study to measure the relationship among serum biomarkers of inflammation and neuronal injury and delirium incidence and severity in a cohort of esophagectomy patients. Methods Blood samples were obtained from patients preoperatively and on postoperative days 1 and 3 and were analyzed for S100 calcium-binding protein B, C-reactive protein (CRP), interleukin (IL) 8 and IL-10, tumor necrosis factor-α, and insulin-like growth factor 1. Delirium was assessed twice daily using the Richmond Agitation Sedation Scale and Confusion Assessment Method for Intensive Care Unit. Delirium severity was assessed once daily with the Delirium Rating Scale–Revised-98. Results Samples from 71 patients were included. Preoperative biomarker concentrations were not associated with postoperative delirium. Significant differences in change in concentrations from preoperatively to postoperative day 1 were seen in IL-8 (delirium, 38.6; interquartile range [IQR], 29.3-69.8; no delirium, 24.8; IQR, 16.0-41.7, P = .022), and IL-10 (delirium, 26.1; IQR, 13.9-36.7; no delirium, 12.4; IQR, 7.7-25.7; P = .025). Greater postoperative increase in S100 calcium-binding protein B (Spearman r = 0.289, P = .020) and lower levels of insulin-like growth factor 1 were correlated with greater delirium severity (Spearman r = −0.27, P = .040). Greater CRP change quartiles were associated with higher delirium incidence adjusting for severity of illness (odds ratio, 1.68; 95% confidence interval, 1.03-2.75; P = .037) or comorbidities (odds ratio, 1.70; 95% confidence interval, 1.05-2.76, P = .030). Conclusions Differences in change in serum CRP, IL-8, and IL-10 concentrations were associated with postoperative delirium, suggesting biomarker measurement early in the postoperative course is associated with delirium.

Coronavirus disease (COVID-19), also known as Severe acute respiratory syndrome (SARS-COV2) and it has imposed deep concern on public health globally. Based on its fast-spreading breakout among the people exposed to the wet animal market in Wuhan city of China, the city was indicated as its origin. The symptoms, reactions, and the rate of recovery shown in the coronavirus cases worldwide have been varied. The number of patients is still rising exponentially, and some countries are now battling the third wave. Since the most effective treatment of this disease has not been discovered so far, early detection of potential COVID-19 patients can help isolate them socially to decrease the spread and flatten the curve. In this study, we explore state-of-the-art research on coronavirus disease to determine the impact of this illness among various age groups. Moreover, we analyze the performance of the Decision tree (DT), K-nearest neighbors (KNN), Naive bayes (NB), Support vector machine (SVM), and Logistic regression (LR) to determine COVID-19 in the patients based on their symptoms. A dataset obtained from a public repository was collected and pre-processed, before applying the selected Machine learning (ML) algorithms on them. The results demonstrate that all the ML algorithms incorporated perform well in determining COVID-19 in potential patients. NB and DT classifiers show the best performance with an accuracy of 93.70%, whereas other algorithms, such as SVM, KNN, and LR, demonstrate an accuracy of 93.60%, 93.50%, and 92.80% respectively. Hence, we determine that ML models have a significant role in detecting COVID-19 in patients based on their symptoms.

Background: Delirium occurs among up to 80% of critically ill patients and is associated with poor patient outcomes. Levels of serum biomarkers of inflammation and astrocytic and glial activation measured at ICU admission are associated with increased delirium duration, delirium severity, and in-hospital mortality. The utility of measuring biomarkers at later points during ICU stay has not been elucidated. Objective: To determine how serum biomarker levels collected at one week of ICU stay are associated with mortality. Design: Observational study. Setting: Three Indianapolis hospitals. Patients: One hundred seventy-eight critically ill patients. Main Results: The median cohort age was 61 years (IQR 53.5-70.1), 56.2% were female, and 48.3% were African American. The median APACHE II score was 21.0 (IQR 16.0-27.0), and the median Charlson Comorbidity Index score was 3.0 (IQR 1.0-5.0). Approximately 76% were mechanically ventilated; 54% had acute respiratory failure and/or sepsis. Median ICU stay was 13 days (IQR 10.0-22.0).We analyzed the relationship between serum biomarkers of inflammation (interleukin-1, 6, 8, 10, and tumor necrosis factor α), neuroprotection (insulin-like growth factor 1), and astrocytic and glial activation (S-100β) and mortality 30 days post-discharge. Higher levels only of IL-6 and IL-10 at day 8 of ICU stay were associated with higher odds of death 30 days post-discharge (IL-6 OR: 2.45, 95% CI: 1.49, 4.03, p

Background Delirium prevention requires optimal management of pain and anxiety. Given the limitations of current pharmacologic interventions, evaluation of novel non-pharmacological interventions is required. Virtual reality (VR) stimulation may be a promising intervention because of its capability to reduce psychophysiological stress, pain, and anxiety and to restore cognitive and attentional capacities. Objective To ascertain patients’ and providers’ perceptions of acceptability and safety of VR intervention in the intensive care unit (ICU). Methods We enrolled a cohort of 15 ICU patients and 21 health care providers to administer a 15-minute session showing a relaxing beach scene with VR headsets and nature sound effects. Participants were then asked to rate their experiences on a Likert scale survey. Results The majority of patients (86%, 12 of 14) rated the headsets as moderately to very comfortable. All had moderate or greater sense of presence in the virtual environment, and 79% (11 of 14) rated their overall experience at 3 or greater (5 indicating that they enjoyed it very much). Seventy-one percent (10 of 14) of the patients felt that their anxiety was better with VR, and 57% (8 of 14) did not notice a change in their pain or discomfort. All health care providers found the headset to be at least moderately comfortable and felt a moderate or greater sense of presence. All providers concluded that VR therapy should be available for their patients. Both groups experienced minimal side effects. Conclusion In this prospective study of perceptions of VR therapy for ICU patients and health care providers, there was a high level of acceptance, with minimal side effects, for both groups despite their low levels of prior experience with virtual reality and video gaming.

The #MeToo Movement has brought sexual harassment, abuse, and assault experienced by females to the forefront of society. Within the athletic realm, this falls under the umbrella term “maltreatment of athletes.” While maltreatment has been reported for decades, victims’ voices have been amplified in recent years. For various political and social reasons, the maltreatment of female athletes from around the world is not as well understood. In this study, female athletes from India and Pakistan reported their perceptions of maltreatment by male coaches. Female athletes with male coaches in both countries participated in this study (N = 395). The athletes represented a large variety of sports (> 26). Participants (Mage = 20.57 ± 2.59; Myears of athletic experience = 2.73 ± 1.49) completed the Sport-Specific Touch and Behaviour Versus Unwanted Intimacy From Coaches questionnaire. Three composite dependent variables were assessed: Unwanted Sexual Behavior, Physical and Verbal Behavior With a Sexual Undertone, and Sexist and Discriminatory Behavior. Main effect differences for the three composite variables were observed for country (p < .001, η2 = .30), with no differences observed for type of sport or the interaction effect. The Pakistani athletes reported greater acceptance of male coaches’ maltreatment than did the Indian athletes. The observed differences were large (i.e., Hedges’ g values ranging from 1.91 to 3.00). Female athletes from Pakistan were more accepting than were Indian athletes of a wide range of sexual maltreatment experiences by their male coaches. There is an urgent need to eradicate such behaviors from the sports world.

Background: Both natural and artificial dentition has an occlusal scheme defined by the shape and positioning of the occlusal contacts. Complete denture fabrication has used a variety of occlusal designs that might have impact on stability of denture and masticatory function. Objective: To determine comparative masticatory performance of bilateral balanced occlusion and lingualized occlusion in complete denture patients Methodology: This study design was randomized trial carried out at the department of Prosthodontics, Altamash Institute of Dental Medicine for duration of six months. A total of 80 subjects were enrolled in the current study and were divided into two groups. Forty subjects were included in each group. In group LO subjects, complete dentures were provided with Lingualized occlusion whereas in group BBO participants, complete dentures were provided with bilateral balanced occlusion. All the required information’s including demographic features were documented in a predesigned Performa. SPSS version 19 was used to enter and analyze all of the data. Results: The mean weight of masticated peanuts in group LO was 5.30gm with standard deviation of 0.89 while in group BBO, the mean weight of masticated peanuts was 9.45gm with standard deviation of 2.10. The difference was significant statistically between two occlusions schemes (p=0.021). Conclusion: Our study concludes that masticatory efficiency was higher in complete dentures patients with lingualized occlusal than bilateral balanced occlusal scheme.. Keywords: Masticatory performance; Bilateral balanced occlusion; Lingualized occlusion

Background Between 30% and 80% of survivors of critical illness experience cognitive impairment, but the underlying mechanisms remain unknown. Objective To determine whether intensive care unit (ICU) delirium biomarkers align with the National Institute on Aging–Alzheimer’s Association (NIA-AA) research framework for diagnostic biomarkers for Alzheimer disease and other related dementias (ADRD). Methods Ovid MEDLINE, PsycInfo, Embase, and the Cochrane Library were systematically searched for articles published between January 1, 2000, and February 20, 2020, on the relationship between delirium and biomarkers listed in the NIA-AA framework. Only studies that addressed delirium in the ICU setting and fluid biomarkers were included in these analyses. Results Of 61 256 records screened, 38 studies met inclusion criteria, 8 of which were suitable for meta-analysis. In pooled analysis, significant associations were found between ICU delirium and amyloid β-peptide 1-40 (standard mean difference [SMD], 0.42; 95% CI, 0.09-0.75), interleukin (IL)-1 receptor antagonist (SMD, 0.58; 95% CI, 0.21-0.94), and IL-6 (SMD, 0.31; 95% CI, 0.06-0.56). No significant association was observed in pooled analyses between ICU delirium and the other biomarkers. Few studies have examined ICU delirium and pathologic tau or neurodegeneration biomarkers. Conclusions Inflammatory biomarkers and amyloid β are associated with ICU delirium and point to potential overlapping mechanisms between delirium and ADRD. Critical care providers should consider integrating diagnostic approaches used in ADRD in their assessment of post–ICU cognitive dysfunction.

Biogenic routes for the synthesis of nanoparticles are environmentally friendly, nontoxic, biocompatible, and cost-effective compared to traditional synthesis methods. In this study, cobalt ferrite was synthesized using Zingiber officinale and Elettaria cardamom Seed extracts. Effect of copper contents (x = 0.0, 0.3, 0.6 and 0.9) on the plant extracted Cux(Co1−xFe2O4) was investigated by XRD, SEM, EDX, UV-Vis., PL, FE-SEM, FTIR and photocatalytic activity. XRD results revealed that nanoparticles exhibit a cubical spinel structure with an average diameter of 7–45 nm, calculated by the Debye Scherer formula. The value of the lattice parameter decreased from 8.36 Å to 8.08 Å with substitution of copper, which can be attributed to mismatch of ionic radii of Cu2+ (0.73 Å) and Co2+ (0.74 Å) ions. SEM analysis showed that nanoparticles exhibit a spherical shape (~13 nm diameter) for undoped samples and low Cu concentration, while they changed to a hexagonal structure at higher Cu concentration (x = 0.9) with a diameter ~46 nm and a decreased degree of agglomeration. FE-SEM further confirmed the nanoparticles’ size and shape. EDX analysis confirmed the presence of cobalt, iron, and oxygen without contamination. The optical absorption spectra of UV-vis and PL showed red-shift, which can be accredited to larger crystalline sizes of nanoparticles. FTIR spectra showed two main bands at 410 and 605 cm−1, indicating the presence of intrinsic vibrations of the octahedral and tetrahedral complexes, respectively. The photocatalytic activity of Co0.4Cu0.6 Fe2O4 nanoparticles was investigated using methylene blue (MB) and methyl orange (MO) dyes under visible light irradiation. The degradation rate (93.39% and 83.15%), regression correlation coefficient (0.9868 and 0.9737) and rate constant (0.04286 and 0.03203 rate·min−1) were calculated for MB and MO, respectively. Mechanisms for the formation and photocatalytic activity of Cu-substituted plant-extracted cobalt ferrite were discussed. The Co0.4Cu0.6 Fe2O4 nanoferrite was found to be an efficient photocatalyst, and can be exploited for wastewater treatment applications for MB/MO elimination.

Rapid increase in population and development in industry causes many problems such as microbial contaminations and chronic diseases such as diabetes. Materials synthesized at nanoscale are novel antidiabetic and antimicrobial agents. ZnO nanoparticles with macropores characteristics are synthesized by green methods. Turmeric, clove buds and green tea extracts are used as additives. X-ray diffraction results confirmed the hexagonal wurtzite structure of ZnO nanoparticles and crystallinity was quit high in case of green tea extract. Sample synthesized with clove shows relatively higher crystallite size (10.64) which is pertaining to variation in Zn

The green synthesis of iron oxide nanoparticles is a convenient, inexpensive, rapid, and ecofriendly method compared to traditional synthesis methods. Magnetic iron oxide nanoparticles with appropriate nanosized exhibit many interesting properties that can be exploited in a variety of biomedical applications. In this regard, we have synthesized magnetite iron oxide (Fe3O4) nanostructures from ferric chloride solution in aqueous extracts of Ficus carica dried fruit. Nanostructures were characterized by X-ray diffractometry (XRD), field emission scanning electron microscopy (FE-SEM), energy-dispersive X-ray spectrometry (EDX), and ultraviolet–visible spectrophotometer (UV–Vis). The XRD study revealed the magnetite structure. FE-SEM results showed various nanoshapes (nanoparticles, nanowires and nanoellipsoids) at different volumetric ratios (1:0.5, 1:0.75, and 1:1) of ferric chloride and extract solution, respectively. At higher concentration of solute, the process of agglomeration started, and the amorphous film is formed. UV–Vis spectroscopy showed the absorption peaks at 220 nm and 302 nm. Chemical composition analysis confirmed the presence of magnetite. Mechanism for the formation of various nanostructures was discussed on the basis of classical nucleation theory. The smaller critical nuclei favor the formation of spherical magnetite nanoparticles at lower concentration. By increasing the concentration, size of the critical nuclei increases resulting in the formation of amorphous film.

Background Our goal was to determine the county-level effect of in-person primary and secondary school reopening on daily cases of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in Indiana. Methods In this county-level, population-based study, we used a panel data regression analysis of the proportion of in-person learning to evaluate an association with community-wide daily new SARS-CoV-2 cases. The study period was 12 July 2020–6 October 2020. We included 73 of 92 (79.3%) Indiana counties in the analysis, accounting for 85.7% of school corporations and 90.6% of student enrollment statewide. The primary exposure was the proportion of students returning to in-person instruction. The primary outcome was the daily new SARS-CoV-2 cases per 100 000 residents at the county level. Results There is a statistically significant relationship between the proportion of students attending K-12 schools in-person and the county level daily cases of SARS-CoV-2 28 days later. For all ages, the coefficient of interest (β) is estimated at 3.36 (95% confidence interval, 1.91 to 4.81; P Conclusions In-person primary and secondary school is associated with a statistically significant but proportionally small increase in the spread of SARS-CoV-2 cases.

The Adaptive User Interface (AUI) adapts to the changes in the context of use and provides improved interaction abilities for different users. The adaptivity in the user interfaces requires in depth knowledge of context. There is a need to enrich user profiles to achieve the personalized services with the ability to adapt the user’s context. The context can be reflected in a particular kind of knowledge and hence modeled as ontology. Ontology based context models are effective means to handle complex situations that support the sharing or integration of context information. This paper presents ontology based context model using OWL for adaptive mobile devices. It models the context over its four major elements including device, user, environment (location and time) and activity. The proposed ontology was derived in different classes, relationships, associations, dependencies and constraints to model dynamic context. Ontologies present a standardized, consistent and shareable context model. The context model and consequent context snapshots can be acknowledged by AUI to present a suitable user interface. The ontology was developed using Protégé on the basis of each context type having different values. Semantic querying (SPARQL) was used for knowledge acquisition. Moreover, the Pellet and HermiT Reasoner were used to verify the rules, relations and constraints to avoid the inconsistency between classes. Comparative to other context models for adaptive interfaces, ontological model provides more of scalability and growth with learning new context in to the shared context knowledge.

Background: The corona virus disease also known as COVID-19 has opened gates to a lot of research about detection, treatment and prevention in the last past year due to lack of information regarding the SARS-CoV-2 virus. PCR corona via nasopharyngeal swab is the standard method of detection in our set-up. Materials and methods: Nasopharyngeal swabs were taken by ENT department using precautions and following proper SOPs. Swabs were sent for rRT-PCR tests. Data was collected and analyzed. All the subjects meeting the inclusion criteria were included in study. Data was analyzed using SPSS version 20. Frequency and percentage was calculated for gender. Positivity rate was calculated using CDC formula. Study design: - Descriptive studies Place and Duration of Study: - Government General Hospital, Ghulam Muhammadabad, Faisalabad. 889 samples were taken from 7.1.2020 to 6.12.2020. Results: Standard PCR for corona test by nasopharyngeal route was taken of suspected corona patients and of patients with contact with corona positive patients. 894 samples were taken from 7.1.2020 to 6.12.2020. 263 were positive for corona. The calculated positive rate is 29.41%. Conclusions: Calculation of positive rates is a very easy metric to give us a quick overview of the spread of the virus. Keywords: COVID-19, Positive rates, PCR-Corona

Objectives To identify whether delirium biomarkers aligned with the National Institute on Aging-Alzheimer's Association (NIA-AA) research framework, a conceptual model that describes the use of diagnostic biomarkers for Alzheimer's disease and other related dementias (ADRD). Design Systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Setting Acute care and outpatient settings. Participants Adults diagnosed with delirium. Methods and measurements MEDLINE, PsycInfo, Embase, and the Cochrane Library were searched for English-language studies published from January 2010 to February 2020. Studies included adults older than 18 years, identified delirium with a standardized assessment tool, and measured an ADRD biomarker. Independent reviewers determined whether an association between delirium and ADRD biomarker was found, the quality of biomarker data based on the REMARK (REporting recommendations for tumor MARKer prognostic studies) checklist, and the study bias based on the Newcastle-Ottawa Scale. Results A total of 61,256 citations were identified; 113 studies were included. Most studies did not examine amyloid, tau, or neurodegeneration biomarkers. Delirium may be associated with neurodegeneration biomarkers, but few to no studies found an association with amyloid and tau biomarkers. Delirium was not consistently associated with inflammatory biomarkers. The quality of biomarker data was moderate, and the risk of bias was moderate to high. Studies often did not collect prehospital and posthospital cognitive data. Conclusion Most delirium diagnostic biomarker studies did not measure amyloid, tau, and/or neurodegenerative biomarkers, making characterization of the relationship between delirium and ADRD difficult. Future delirium biomarker diagnostic studies could improve the understanding of pathophysiologic links between delirium with other conditions affecting cognition.

Background: After critical illness, new or worsening impairments in physical, cognitive, and/or mental health function are common among patients who have survived. Who should be screened for long-term impairments, what tools to use, and when remain unclear. Objectives: Provide pragmatic recommendations to clinicians caring for adult survivors of critical illness related to screening for postdischarge impairments. Participants: Thirty-one international experts in risk-stratification and assessment of survivors of critical illness, including practitioners involved in the Society of Critical Care Medicine’s Thrive Post-ICU Collaboratives, survivors of critical illness, and clinical researchers. Design: Society of Critical Care Medicine consensus conference on post-intensive care syndrome prediction and assessment, held in Dallas, in May 2019. A systematic search of PubMed and the Cochrane Library was conducted in 2018 and updated in 2019 to complete an original systematic review and to identify pre-existing systematic reviews. Meeting Outcomes: We concluded that existing tools are insufficient to reliably predict post-intensive care syndrome. We identified factors before (e.g., frailty, preexisting functional impairments), during (e.g., duration of delirium, sepsis, acute respiratory distress syndrome), and after (e.g., early symptoms of anxiety, depression, or post-traumatic stress disorder) critical illness that can be used to identify patients at high-risk for cognitive, mental health, and physical impairments after critical illness in whom screening is recommended. We recommend serial assessments, beginning within 2–4 weeks of hospital discharge, using the following screening tools: Montreal Cognitive Assessment test; Hospital Anxiety and Depression Scale; Impact of Event Scale-Revised (post-traumatic stress disorder); 6-minute walk; and/or the EuroQol-5D-5L, a health-related quality of life measure (physical function). Conclusions: Beginning with an assessment of a patient’s pre-ICU functional abilities at ICU admission, clinicians have a care coordination strategy to identify and manage impairments across the continuum. As hospital discharge approaches, clinicians should use brief, standardized assessments and compare these results to patient’s pre-ICU functional abilities (“functional reconciliation”). We recommend serial assessments for post-intensive care syndrome-related problems continue within 2–4 weeks of hospital discharge, be prioritized among high-risk patients, using the identified screening tools to prompt referrals for services and/or more detailed assessments.

Rationale: Delirium severity and duration are independently associated with higher mortality and morbidity. No studies to date have described a delirium trajectory by integrating both severity and duration. Objectives: The primary aim was to develop delirium trajectories by integrating symptom severity and duration. The secondary aim was to investigate the association among trajectory membership, clinical characteristics, and 30-day mortality. Methods: A secondary analysis of the PMD (Pharmacologic Management of Delirium) randomized control trial (ClinicalTrials.gov Identifier: NCT00842608; N = 531) was conducted. The presence of delirium and symptom severity were measured at least daily for 7 days using the Confusion Assessment Method for the intensive care unit (CAM-ICU) and CAM-ICU-7 (on a scale of 0–7, with 7 being the most severe). Delirium trajectories were defined using an innovative, data-driven statistical method (group-based trajectory modeling [GBTM]) and SAS v9.4. Results: A total of 531 delirious participants (mean age 60 yr [standard deviation = 16], 55% female, and 46% African American) were analyzed. Five distinct delirium trajectories were described (CAM-ICU-7: mean [standard deviation]); mild-brief (CAM-ICU-7: 0.5 [0.5]), severe-rapid recovers (CAM-ICU-7: 2.1 [1.0]), mild-accelerating (CAM-ICU-7: 2.2 [0.9]), severe-slow recovers (CAM-ICU-7: 3.9 [0.9]), and severe-nonrecovers (CAM-ICU-7: 5.9 [1.0]). Baseline cognition and race were associated with trajectory membership. Trajectory membership independently predicted 30-day mortality while controlling for age, sex, race, cognition, illness severity, and comorbidities. Conclusions: This secondary analysis described five distinct delirium trajectories based on delirium symptom severity and duration using group-based trajectory modeling. Trajectory membership predicted 30-day mortality.

Objectives: One of the defining features of the novel coronavirus disease 2019 infection has been high rates of venous thromboses. The present study aimed to describe the prevalence of venous thromboembolism in critically ill patients receiving different regimens of prophylactic anticoagulation. Design: Single-center retrospective review using data from patients with confirmed severe acute respiratory syndrome coronavirus 2 requiring intubation. Setting: Tertiary-care center in Indianapolis, IN, United States. Patients: Patients hospitalized at international units Health Methodist Hospital with severe acute respiratory syndrome coronavirus 2 requiring intubation between March 23, 2020, and April 8, 2020, who underwent ultrasound evaluation for venous thrombosis. Interventions: None. Measurements and Main Results: A total of 45 patients were included. Nineteen of 45 patients (42.2%) were found to have deep venous thrombosis. Patients found to have deep venous thrombosis had no difference in time to intubation (p = 0.97) but underwent ultrasound earlier in their hospital course (p = 0.02). Sequential Organ Failure Assessment scores were similar between the groups on day of intubation and day of ultrasound (p = 0.44 and p = 0.07, respectively). d-dimers were markedly higher in patients with deep venous thrombosis, both for maximum value and value on day of ultrasound (p < 0.01 for both). Choice of prophylactic regimen was not related to presence of deep venous thrombosis (p = 0.35). Ultrasound evaluation is recommended if d-dimer is greater than 2,000 ng/mL (sensitivity 95%, specificity 46%) and empiric anticoagulation considered if d-dimer is greater than 5,500 ng/mL (sensitivity 53%, specificity 88%). Conclusions: Deep venous thrombosis is very common in critically ill patients with coronavirus disease 2019. There was no difference in incidence of deep venous thrombosis among different pharmacologic prophylaxis regimens, although our analysis is limited by small sample size. d-dimer values are elevated in the majority of these patients, but there may be thresholds at which screening ultrasound or even empiric systemic anticoagulation is indicated.

OBJECTIVES Mean arterial pressure is critically important in patients with cirrhosis in the ICU, however, there is limited data to guide therapies and targets. DESIGN Retrospective observational study. SETTING Tertiary care ICU. PATIENTS Two hundred and seventy-three critically ill patients with cirrhosis. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We performed a comprehensive time-weighted mean arterial pressure analysis (time-weighted-average-mean arterial pressure and cumulative-time-below various mean arterial pressure-thresholds) during the first 24-hours after ICU admission (median: 25 mean arterial pressure measurements per-patient). Time-weighted-average-mean arterial pressure captures both the severity and duration of hypotension below a mean arterial pressure threshold and cumulative-time-below is the total time spent below a mean arterial pressure threshold. Individual univariable and multivariable logistic regression models were assessed for each time-weighted-average-mean arterial pressure and cumulative-time-below mean arterial pressure threshold (55, 60, 65, 70, and 75 mm Hg) for ICU-mortality. Time-weighted-average-mean arterial pressure: for 1 mm Hg decrease in mean arterial pressure below 75, 70, 65, 60, and 55 mm Hg, the odds for ICU-mortality were 14%, 18%, 26%, 41%, and 74%, respectively (p < 0.01, all thresholds). The association between time-weighted-average-mean arterial pressure and ICU-mortality for each threshold remained significant after adjusting for model for end-stage liver disease-sodium score, mechanical ventilation, vasopressor use, renal replacement therapy, grade 3/4 hepatic encephalopathy, WBC count, and albumin. Cumulative-time-below: odds for ICU-mortality were 4%, 6%, 10%, 12%, and 12% for each-hour spent below 75, 70, 65, 60, and 55 mm Hg, respectively. In the adjusted models, significant associations only remained for mean arterial pressure less than 65 mm Hg (odds ratio, 1.07; 95% CI, 1.00-1.14; p = 0.05) and < 60 mm Hg (odds ratio, 1.10; 95% CI, 1.01-1.18; p = 0.04). CONCLUSIONS These data suggest that maintaining a mean arterial pressure of greater than 65 mm Hg may be a reasonable target in patients with cirrhosis admitted to the ICU. However, further prospective randomized trials are needed to determine the optimal mean arterial pressure-targets in this patient population.

Objectives Both delirium duration and delirium severity are associated with adverse patient outcomes. Serum biomarkers associated with delirium duration and delirium severity in ICU patients have not been reliably identified. We conducted our study to identify peripheral biomarkers representing systemic inflammation, impaired neuroprotection, and astrocyte activation associated with delirium duration, delirium severity, and in-hospital mortality. Design Observational study. Setting Three Indianapolis hospitals. Patients Three-hundred twenty-one critically ill delirious patients. Interventions None. Measurements and main results We analyzed the associations between biomarkers collected at delirium onset and delirium-/coma-free days assessed through Richmond Agitation-Sedation Scale/Confusion Assessment Method for the ICU, delirium severity assessed through Confusion Assessment Method for the ICU-7, and in-hospital mortality. After adjusting for age, gender, Acute Physiology and Chronic Health Evaluation II score, Charlson comorbidity score, sepsis diagnosis and study intervention group, interleukin-6, -8, and -10, tumor necrosis factor-α, C-reactive protein, and S-100β levels in quartile 4 were negatively associated with delirium-/coma-free days by 1 week and 30 days post enrollment. Insulin-like growth factor-1 levels in quartile 4 were not associated with delirium-/coma-free days at both time points. Interleukin-6, -8, and -10, tumor necrosis factor-α, C-reactive protein, and S-100β levels in quartile 4 were also associated with delirium severity by 1 week. At hospital discharge, interleukin-6, -8, and -10 retained the association but tumor necrosis factor-α, C-reactive protein, and S-100β lost their associations with delirium severity. Insulin-like growth factor-1 levels in quartile 4 were not associated with delirium severity at both time points. Interleukin-8 and S-100β levels in quartile 4 were also associated with higher in-hospital mortality. Interleukin-6 and -10, tumor necrosis factor-α, and insulin-like growth factor-1 were not found to be associated with in-hospital mortality. Conclusions Biomarkers of systemic inflammation and those for astrocyte and glial activation were associated with longer delirium duration, higher delirium severity, and in-hospital mortality. Utility of these biomarkers early in delirium onset to identify patients at a higher risk of severe and prolonged delirium, and delirium related complications during hospitalization needs to be explored in future studies.

Background The effect of delirium on physical function in patients undergoing noncardiac thoracic surgery has not been well described and may differ from that in other surgical populations. Objective To determine the effects of delirium on muscle strength and functional independence. The primary end point was change in Medical Research Council sum score (MRC-SS) by delirium status. Methods A secondary analysis of data from a clinical trial involving English-speaking adults aged 18 years or older who were undergoing major noncardiac thoracic surgery. Exclusion criteria were history of schizophrenia, Parkinson disease, dementia, alcohol abuse, or neuroleptic malignant syndrome; haloperidol allergy; being pregnant or nursing; QT prolongation; and taking levodopa or cholinesterase inhibitors. Delirium was assessed twice daily using the Confusion Assessment Method for the Intensive Care Unit. Preoperatively and postoperatively, muscle strength was assessed using the modified MRC-SS and functional independence was assessed using the Katz scale of activities of daily living. Changes in MRC-SS and Katz score by delirium status were analyzed using the Fisher exact test. Results Seventy-three patients were included in the analysis. Median (interquartile range) MRC-SS and Katz score before surgery did not differ significantly between patients without and with delirium (MRC-SS: 30 [30-30] vs 30 [30-30], P > .99; Katz score: 6 [6-6] vs 6 [6-6], P = .63). The percentage of patients with a change in MRC-SS was similar in patients without and with delirium (17% vs 13%, respectively; P > .99). More patients in the delirium group had a change in Katz score (13% vs 0%, P = .04). Conclusions Postoperative delirium was not associated with change in muscle strength. Follow-up studies using other muscle measures may be needed.

Background Management of delirium in intensive care units is challenging because effective therapies are lacking. Music is a promising nonpharmacological intervention. Objectives To determine the feasibility and acceptability of personalized music (PM), slow-tempo music (STM), and attention control (AC) in patients receiving mechanical ventilation in an intensive care unit, and to estimate the effect of music on delirium. Methods A randomized controlled trial was performed in an academic medical-surgical intensive care unit. After particular inclusion and exclusion criteria were applied, patients were randomized to groups listening to PM, relaxing STM, or an audiobook (AC group). Sessions lasted 1 hour and were given twice daily for up to 7 days. Patients wore noise-canceling headphones and used mp3 players to listen to their music/audiobook. Delirium and delirium severity were assessed twice daily by using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and the CAM-ICU-7, respectively. Results Of the 1589 patients screened, 117 (7.4%) were eligible. Of those, 52 (44.4%) were randomized, with a recruitment rate of 5 patients per month. Adherence was higher in the groups listening to music (80% in the PM and STM groups vs 30% in the AC group; P = .01), and 80% of patients surveyed rated the music as enjoyable. The median number (interquartile range) of delirium/coma-free days by day 7 was 2 (1-6) for PM, 3 (1-6) for STM, and 2 (0-3) for AC (P = .32). Median delirium severity was 5.5 (1-7) for PM, 3.5 (0-7) for STM, and 4 (1-6.5) for AC (P = .78). Conclusions Music delivery is acceptable to patients and is feasible in intensive care units. Further research testing use of this promising intervention to reduce delirium is warranted.

Background In-hospital respiratory outcomes of non-surgical patients with undiagnosed obstructive sleep apnea (OSA), particularly those with significant comorbidities are not well defined. Undiagnosed and untreated OSA may be associated with increased cardiopulmonary morbidity. Study objectives Evaluate respiratory failure outcomes in patients identified as at-risk for OSA by the Berlin Questionnaire (BQ). Methods This was a retrospective study conducted using electronic health records at a large health system. The BQ was administered at admission to screen for OSA to medical-service patients under the age of 80 years old meeting the following health system criteria: (1) BMI greater than 30; (2) any of the following comorbid diagnoses: hypertension, heart failure, acute coronary syndrome, pulmonary hypertension, arrhythmia, cerebrovascular event/stroke, or diabetes. Patients with known OSA or undergoing surgery were excluded. Patients were classified as high-risk or low-risk for OSA based on the BQ score as follows: low-risk (0 or 1 category with a positive score on the BQ); high-risk (2 or more categories with a positive score on BQ). The primary outcome was respiratory failure during index hospital stay defined by any of the following: orders for conventional ventilation or intubation; at least two instances of oxygen saturation less than 88% by pulse oximetry; at least two instances of respiratory rate over 30 breaths per minute; and any orders placed for non-invasive mechanical ventilation without a previous diagnosis of sleep apnea. Propensity scores were used to control for patient characteristics. Results Records of 15,253 patients were assessed. There were no significant differences in the composite outcome of respiratory failure by risk of OSA (high risk: 11%, low risk: 10%, p = 0.55). When respiratory failure was defined as need for ventilation, more patients in the low-risk group experienced invasive mechanical ventilation (high-risk: 1.8% vs. low-risk: 2.3%, p = 0.041). Mortality was decreased in patients at high-risk for OSA (0.86%) vs. low risk for OSA (1.53%, p Conclusions Further prospective studies are needed to understand the contribution of undiagnosed OSA to in-hospital respiratory outcomes.