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Background and purpose: Targeted temperature management (TTM) has been recommended for post-resuscitation care of cardiac arrest (CA) patients who remain comatose. However, the differences between cardiogenic and non-cardiogenic causes need further investigation. Thus, this study aimed to investigate the difference in outcomes between cardiogenic and non-cardiogenic CA patients receiving TTM. Methods: The TIMECARD registry established the study cohort and database for patients receiving TTM between January 2013 and September 2019. A total of 543 patients were enrolled, with 305 and 238 patients in the cardiogenic and non-cardiogenic groups, respectively. Results: Compared with the non-cardiogenic group, the cardiogenic group had higher proportion of initial shockable rhythm, better survival (cardiogenic: 45.9%; non-cardiogenic: 30.7%, P = 0.0017), and better neurologic performance at discharge. In the cardiogenic group, witnessed collapse (OR = 0.31, 95% CI: 0.13–0.72), and coronary intervention (OR = 0.45, 95% CI: 0.24–0.84) were positive predictors for overall outcome. Mean arterial pressure

Abstract Background Severe vitamin D deficiency (SVDD) dramatically increases the risks of mortality, infections, and many other diseases. Studies have reported higher prevalence of vitamin D deficiency in patients with critical illness than general population. This multicenter retrospective cohort study develops and validates a score-based model for predicting SVDD in patients with critical illness. Methods A total of 662 patients with critical illness were enrolled between October 2017 and July 2020. SVDD was defined as a serum 25(OH)D level of

Purpose: To compare the clinical effectiveness of branded versus generic piperacillin-tazobactam for treating severe community-acquired pneumonia (CAP). Patients and methods: We identified patients with severe CAP who received piperacillin-tazobactam based on a nine-center registry database. Furthermore, we classified the patients in three hospitals, which used only branded piperacillin-tazobactam as the study group, and the patients in six other hospitals, which used both branded and generic products as the control group. Results: A total of 472 patients (n = 263 in the study group and n = 209 in the control group) with severe CAP were included. The study group using branded piperacillin-tazobactam had higher odds of clinical cure (adjusted odds ratio [OR] = 3.77, 95 % confidence interval [CI], 1.93–7.37) and lower odds of treatment failure (adjusted OR = 0.28, 95 % CI, 0.13–0.58) than the control group receiving either branded or generic piperacillin-tazobactam. In addition, the study group was associated with higher odds of clinical effectiveness (adjusted OR = 2.95, 95 % CI, 1.46–6.11), less odds of clinical ineffectiveness (adjusted OR = 0.39, 95 % CI, 0.18–0.81), and lower risk of in-hospital mortality (adjusted OR = 0.39, 95 % CI, 0.21–0.73). Conclusion: Based on the findings of the present study using indirect comparison, the clinical effectiveness of generic piperacillin-tazobactam for treating patients with severe CAP might not be as good as that of brand-name products.

Abstract Background Post-resuscitation hemodynamic level is associated with outcomes. This study was conducted to investigate if post-resuscitation diastolic blood pressure (DBP) is a favorable prognostic factor. Methods Using TaIwan Network of Targeted Temperature ManagEment for CARDiac Arrest (TIMECARD) registry, we recruited adult patients who received targeted temperature management in nine medical centers between January 2014 and September 2019. After excluding patients with extracorporeal circulation support, 448 patients were analyzed. The first measured, single-point blood pressure after resuscitation was used for analysis. Study endpoints were survival to discharge and discharge with favorable neurologic outcomes (CPC 1–2). Multivariate analysis, area under the receiver operating characteristic curve (AUC), and generalized additive model (GAM) were used for analysis. Results Among the 448 patients, 182 (40.7%) patients survived, and 89 (19.9%) patients had CPC 1–2. In the multivariate analysis, DBP > 70 mmHg was an independent factor for survival (adjusted odds ratio [aOR] 2.16, 95% confidence interval [CI, 1.41–3.31]) and > 80 mmHg was an independent factor for CPC 1–2 (aOR 2.04, 95% CI [1.14–3.66]). GAM confirmed that DBP > 80 mmHg was associated with a higher likelihood of CPC 1–2. In the exploratory analysis, patients with DBP > 80 mmHg had a significantly higher prevalence of cardiogenic cardiac arrest (p = 0.015) and initial shockable rhythm (p = 0.045). Conclusion We found that DBP after resuscitation can predict outcomes, as a higher DBP level correlated with cardiogenic cardiac arrest.

Background: Target temperature management (TTM) is a recommended therapy for patients after cardiac arrest (PCA). The TaIwan Network of Targeted Temperature ManagEment for CARDiac Arrest (TIMECARD) registry was established for PCA who receive TTM therapy in Taiwan. We aim to determine the variables that may affect neurologic outcomes in PCA who undergo TTM. Methods: We retrieved demographic variables, resuscitation variables, and cerebral performance category (CPC) scale score at hospital discharge from the TIMECARD registry. The primary outcome was a favorable neurologic outcome, defined as a CPC scale of 1 or 2 at discharge. A total of 540 PCA treated between January 2014 and September 2019 were identified from the registry. Univariate and multivariate analyses were performed to identify significant variables. Results: The mortality rate was 58.1% (314/540). Favorable neurologic outcomes were noted in 117 patients (21.7%). The factors significantly influencing the neurologic outcome (p

Background and PurposeTargeted temperature management (TTM) is associated with decreased mortality and improved neurological function after cardiac arrest. Additionally, studies have shown that bystander cardiopulmonary resuscitation (BCPR) doubled the survival of patients with out-of-hospital cardiac arrest (OHCA) compared to patients who received no BPCR (no-BCPR). However, the outcome benefits of BCPR on patients who received TTM are not fully understood. Therefore, this study aimed to investigate the outcome differences between BCPR and no-BCPR in patients who received TTM after cardiac arrest.MethodsThe Taiwan Network of Targeted Temperature Management for Cardiac Arrest (TIMECARD) multicenter registry established a study cohort and a database for patients receiving TTM between January 2013 and September 2019. A total of 580 patients were enrolled and divided into 376 and 204 patients in the BCPR and no-BCPR groups, respectively.ResultsCompared to the no-BCPR group, the BCPR group had a better hospital discharge and survival rate (42.25 vs. 31.86%, P = 0.0305). The BCPR group also had a better neurological outcome at hospital discharge. It had a higher average GCS score (11.3 vs. 8.31, P < 0.0001) and a lower average Glasgow–Pittsburgh cerebral performance category (CPC) scale score (2.14 vs. 2.98, P < 0.0001). After undertaking a multiple logistic regression analysis, it was found that BCPR was a significant positive predictor for in-hospital survival (OR = 0.66, 95% CI: 0.45–0.97, P = 0.0363).ConclusionsThis study demonstrated that BCPR had a positive survival and neurological impact on the return of spontaneous circulation (ROSC) in patients receiving TTM after cardiac arrest.

Background: Vitamin D deficiency is common in the general population worldwide, and the prevalence and severity of vitamin D deficiency increase in critically ill patients. The prevalence of vitamin D deficiency in a community-based cohort in Northern Taiwan was 22.4%. This multicenter cohort study investigated the prevalence of vitamin D deficiency and associated factors in critically ill patients in Northern Taiwan.Methods: Critically ill patients were enrolled and divided into five groups according to their length of stay at intensive care units (ICUs) during enrolment as follows: group 1,

Summary: Background: The objective of this study was to investigate whether the nutrition intake from enteral nutrition (EN) and parenteral nutrition (PN) created a better clinical outcome than EN alone in high nutritional risk (HNR) mechanically ventilated critically ill elderly patients. Methods: We included patients ≥ 65 years on mechanical ventilation ≥ 48 h and received EN. Nutritional status was evaluated by Modify NUTrition Risk in Critical ill score (mNUTRIC). We calculated the energy and protein requirements as Harris-Benedict equation × 1.0–1.3 and 1.0–2.0 gm/kg body weight respectively. Nutrition intake from EN and PN was recorded within 7 days. ICU and hospital mortalities in HNR elderly patients who could achieve more or less 80% prescribed nutrition were compared. Result: Among 190 critically ill elderly patients, 173 (91.1%) HNR patients had mNUTRIC ≥ 5. HNR patients who achieved ≥80% prescribed calorie had lower ICU mortality (13.5% vs 25.8%; P = 0.04) and hospital mortality (23.4% vs 40.3%; P = 0.02) compared to those who achieved

Extracorporeal membrane oxygenation (ECMO) is a high-risk extracorporeal technique that serves as an effective last-ditch salvage therapy for patients with severe heart or respiratory failure. The most common complications observed after ECMO include hypoxic and vascular lesions (ischemic or hemorrhagic). Neurologic complications contribute to a proportion of post-treatment morbidity and mortality but have seldom been well described. We present the case of a 26-year-old man with complications related to influenza A pneumonia and who experienced sudden-onset paraplegia after undergoing ECMO. A magnetic resonance imaging scan revealed spinal infarction at the T9 to L1 level, likely involving the artery of Adamkiewicz. This may be attributed to spinal hypoperfusion or thromboembolism. Similar previously reported cases show a large variation in the ECMO duration; however, the venoarterial mode of ECMO was commonly used in cases involving this complication. Although spinal infarction is rarely reported to occur in clinical practice after ECMO complications, it requires a high index of suspicion for recognition. Close monitoring of coagulation and platelet count and electrophysiological recording during ECMO may be useful in early detection and prevention of complications.

Coronavirus disease-2019 (COVID-19) causes severe pneumonia and acute respiratory distress syndrome. According to the current consensus, immunosuppressants, such as dexamethasone and anti-interleukin-6 receptor monoclonal antibodies, are therapeutic medications in the early stages of infection. However, in critically ill patients, viral, fungal, and bacterial coinfection results in higher mortality. We conducted a single-center, retrospective analysis of 29 mechanically ventilated patients with artificial airways. Patients were adults with confirmed COVID-19 infection and severe pneumonia. Acute respiratory distress syndrome was diagnosed according to the Kigali modification of the Berlin definition. Six patients had invasive pulmonary aspergillosis coinfection based on elevated serum galactomannan levels and/or bronchoalveolar lavage fluid. We present two cases with brief histories and available clinical data. We also conducted a literature review to determine whether immunosuppressants, such as tocilizumab, increase infection risk or invasive aspergillosis in patients with COVID-19. There is no conclusive evidence to suggest that tocilizumab increases coinfection risk. However, further studies are needed to determine the optimal dose, between-dose interval, and timing of tocilizumab administration in patients with COVID-19.

Background and Objectives: Traditional assessment of the readiness for the weaning from the mechanical ventilator (MV) needs respiratory parameters in a spontaneous breath. Exempted from the MV disconnecting and manual measurements of weaning parameters, a prediction model based on parameters from MV and electronic medical records (EMRs) may help the assessment before spontaneous breath trials. The study aimed to develop prediction models using machine learning techniques with parameters from the ventilator and EMRs for predicting successful ventilator mode shifting in the medical intensive care unit. Materials and Methods: A retrospective analysis of 1483 adult patients with mechanical ventilators for acute respiratory failure in three medical intensive care units between April 2015 and October 2017 was conducted by machine learning techniques to establish the predicting models. The input candidate parameters included ventilator setting and measurements, patients’ demographics, arterial blood gas, laboratory results, and vital signs. Several classification algorithms were evaluated to fit the models, including Lasso Regression, Ridge Regression, Elastic Net, Random Forest, Extreme Gradient Boosting (XGBoost), Support Vector Machine, and Artificial Neural Network according to the area under the Receiver Operating Characteristic curves (AUROC). Results: Two models were built to predict the success shifting from full to partial support ventilation (WPMV model) or from partial support to the T-piece trial (sSBT model). In total, 3 MV and 13 nonpulmonary features were selected for the WPMV model with the XGBoost algorithm. The sSBT model was built with 8 MV and 4 nonpulmonary features with the Random Forest algorithm. The AUROC of the WPMV model and sSBT model were 0.76 and 0.79, respectively. Conclusions: The weaning predictions using machine learning and parameters from MV and EMRs have acceptable performance. Without manual measurements, a decision-making system would be feasible for the continuous prediction of mode shifting when the novel models process real-time data from MV and EMRs.

Background: Due to studies on calorie requirement in mechanically ventilated critically ill elderly patients are few, and indirect calorimetry (IC) is not available in every intensive care unit (ICU). The aim of this study was to compare IC and Harris–Benedict (HB) predictive equation in different BMI groups. Methods: A total of 177 mechanically ventilated critically ill elderly patients (≧65 years old) underwent IC for measured resting energy expenditure (MREE). Estimated calorie requirement was calculated by the HB equation, using actual body weight (ABW) and ideal body weight (IBW) separately. Patients were divided into four BMI groups. One-way ANOVA and Pearson's correlation coefficient were used for statistical analyses. Results: The mean MREE was 1443.6 ± 318.2 kcal/day, HB(ABW) was 1110.9 ± 177.0 kcal/day and HB(IBW) was 1101.5 ± 113.1 kcal/day. The stress factor (SFA = MREE ÷ HB(ABW)) was 1.43 ± 0.26 for the underweight, 1.30 ± 0.27 for the normal weight, 1.20 ± 0.19 for the overweight, and 1.20 ± 0.31 for the obese. The SFI (SFI = MREE ÷ HB(IBW)) was 1.24 ± 0.24 for the underweight, 1.31 ± 0.26 for the normal weight, 1.36 ± 0.21 for the overweight, and 1.52 ± 0.39 for the obese. MREE had significant correlation both with REE(ABW) = HB(ABW) × SFA (r = 0.46; P

Nutritional status could affect clinical outcomes in critical patients. We aimed to determine the prognostic accuracy of the modified Nutrition Risk in Critically Ill (mNUTRIC) score for hospital mortality and treatment outcomes in patients with severe community-acquired pneumonia (SCAP) compared to other clinical prediction rules. We enrolled SCAP patients in a multi-center setting retrospectively. The mNUTRIC score and clinical prediction rules for pneumonia, as well as clinical factors, were calculated and recorded. Clinical outcomes, including mortality status and treatment outcome, were assessed after the patient was discharged. We used the receiver operating characteristic (ROC) curve method and multivariate logistic regression analysis to determine the prognostic accuracy of the mNUTRIC score for predicting clinical outcomes compared to clinical prediction rules, while 815 SCAP patients were enrolled. ROC curve analysis showed that the mNUTRIC score was the most effective at predicting each clinical outcome and had the highest area under the ROC curve value. The cut-off value for predicting clinical outcomes was 5.5. By multivariate logistic regression analysis, the mNUTRIC score was also an independent predictor of both clinical outcomes in SCAP patients. We concluded that the mNUTRIC score is a better prognostic factor for predicting clinical outcomes in SCAP patients compared to other clinical prediction rules.

Background: The purpose of this study was to evaluate the efficacy and safety of Xylocaine spray for the pain caused by endotracheal tube, and its impact on patients’ satisfaction of intensive care. Methods: A quantitative evaluation of the effect before and after Xylocaine spray on endotracheal tube pain relief, and a qualitative interview study of the impact of this intervention on patients’ satisfaction of intensive care in a prospective, clinical investigation. Those in the medical intensive care unit being endotracheal intubated and being able to clearly communicate with the caregivers were enrolled after providing their inform consent. We prescribed Xylocaine 10% pump spray as frequently as demanded. Results: Nineteen patients were eligible for this study. The numerical rating scale of the throat pain before local Xylocaine spray were 8.82±0.79, 7.98±0.92, 7.07±0.76, 6.37±0.83 and 5.47±1.23, sequentially, compared with after therapy results, which were 3.84±0.86, 3.57±0.74, 3.06±0.70, 2.61±0.77 and 1.96±0.88 (p

Oxysterols are oxidation products of cholesterol. Cholestane-3β, 5α, 6β-triol (abbreviated as triol) is one of the most abundant and active oxysterols. Here, we report that triol exhibits anti-cancer activity against human prostate cancer cells. Treatment of cells with triol dose-dependently suppressed proliferation of LNCaP CDXR-3, DU-145, and PC-3 human prostate cancer cells and reduced colony formation in soft agar. Oral administration of triol at 20 mg/kg daily for three weeks significantly retarded the growth of PC-3 xenografts in nude mice. Flow cytometric analysis revealed that triol treatment at 10-40 µM caused G1 cell cycle arrest while the TUNEL assay indicated that triol treatment at 20-40 µM induced apoptosis in all three cell lines. Micro-Western Arrays and traditional Western blotting methods indicated that triol treatment resulted in reduced expression of Akt1, phospho-Akt Ser473, phospho-Akt Thr308, PDK1, c-Myc, and Skp2 protein levels as well as accumulation of the cell cycle inhibitor p27(Kip). Triol treatment also resulted in reduced Akt1 protein expression in PC-3 xenografts. Overexpression of Skp2 in PC-3 cells partially rescued the growth inhibition caused by triol. Triol treatment suppressed migration and invasion of DU-145, PC-3, and CDXR-3 cells. The expression levels of proteins associated with epithelial-mesenchymal transition as well as focal adhesion kinase were affected by triol treatment in these cells. Triol treatment caused increased expression of E-cadherin protein levels but decreased expression of N-cadherin, vimentin, Slug, FAK, phospho-FAK Ser722, and phospho-FAK Tyr861 protein levels. Confocal laser microscopy revealed redistribution of β-actin and α-tubulin at the periphery of the CDXR-3 and DU-145 cells. Our observations suggest that triol may represent a promising therapeutic agent for advanced metastatic prostate cancer.

Background: Vitamin D is an important nutrient for maintaining cardiovascular, endocrine, immune, and nervous system health. Body mass index (BMI) is one of the factors influencing vitamin D levels. We aimed to study the factors that play a role in the outcomes and prognoses of critically ill patients. Method: This study was conducted at four teaching hospitals in Northern Taiwan between August 2018 and July 2020. A total of 1421 critically ill patients admitted to the intensive care units (ICUs) were eligible for assessment. Patients were classified into two groups based on serum 25(OH)D levels: sufficiency ( 20 ng/ml) and insufficiency (< 20 ng/ml); and into four groups according to BMI: underweight (BMI < 18.5), normal weight (BMI 18.5-24.9), overweight (BMI 25-29.9), and obesity (BMI 30). Statistical analyses were performed, and a p-value < 0.05 indicated a significant difference. Results: More than half (57.9%) of the critically ill ICU patients had vitamin D deficiency (VDD); and VDD lengthened ICU stay by 2.5 days in vitamin D-deficit patients as compared to that in vitamin D-sufficient patients. Patients with obesity had a 4.2-day longer ICU stay (16.7 days) than that of the BMI < 30 group (12.5 days), which was significant (p = 0.009). They also had the lowest vitamin D levels (17.3 ng/mL) and the highest 90-day mortality rate (17.3%) compared to the other BMI groups. Conclusion: In caring for critical patients, physicians need to pay more attention to vitamin D levels and BMI factors, which may impact their outcome prediction. [ABSTRACT FROM AUTHOR]

Background: Postextubation respiratory failure is associated with increased mortality. The role of high-flow nasal cannula (HFNC) oxygen therapy in high-risk patients has not been clarified in postextubation failure. This study aimed to determine whether HFNC reduces postextubation respiratory failure in high-risk patients compared with conventional oxygen therapy. Methods: A single-center randomized controlled trial was conducted in Taiwan's 25-bed adult medical intensive care units (ICUs) from September 2014 to September 2016. Enrolled patients with high-risk postextubation failure were randomized to receive either HFNC or conventional oxygen therapy for 72 hours postextubation. Primary outcomes were rate and causes of postextubation respiratory failure within 72 hours. Secondary outcomes included the ICU length of stay, 28-day mortality, and 48-hour postextubation physiologic values. Results: Of 56 patients, 29 received HFNC and 27 received conventional oxygenation therapy. Fewer patients developed respiratory failure in the HFNC (0/29, 0%) than in the Conventional Group (7/27, 25.9%) (odds ratio 0.408 [95% confidence interval, 0.29-0.57], p = 0.0038). There was no significant difference in the ICU length of stay, 28-day postextubation mortality, multiorgan failure, or the 48-hour postextubation physiologic variables. However, there was a trend toward better oxygenation in the HFNC Group (102.4 ± 25.4 vs. 86.6 ± 26.4 mmHg, p = 0.148). Conclusion: Among patients at high risk for extubation failure, HFNC reduced the risk of postextubation respiratory failure compared to conventional oxygen therapy. [ABSTRACT FROM AUTHOR]

Dynamic recrystallization (DRX) behaviors of solution-treated Ni-based and aged superalloys under stepped strain rates were investigated by hot compressive tests and metallographic technique. The stepped strain rate means that the strain rate of specimen includes two stages, I and II. Moreover, the strain rate of stage I is larger than that of stage II for this study. The experimental results show that: (1) for the solution-treated Ni-based superalloy, the DRX fraction of deformed specimen at stepped strain rate is in between those of two specimens deformed at the constant strain rates of stages I and II; (2) however, for aged Ni-based superalloy, the DRX fraction of deformed specimen at stepped strain rate is larger those of two specimens deformed at the constant strain rates of stages I and II. It indicates that the stepped strain rate cannot accelerate the DRX behaviors of solution-treated Ni-based superalloy, but can accelerate the DRX behaviors of aged one. The reason is that the number of likely nucleation positions for the aged Ni-based superalloy is more than that for solution-treated one when the strain rate is abruptly decreased. The law can be applied in the hot working of the studied superalloy. [ABSTRACT FROM AUTHOR]

Background: Post-cardiac arrest care is critically important in bringing cardiac arrest patients to functional recovery after the detrimental event. More high quality studies are published and evidence is accumulated for the post-cardiac arrest care in the recent years. It is still a challenge for the clinicians to integrate these scientific data into the real clinical practice for such a complicated intensive care involving many different disciplines. Methods: With the cooperation of the experienced experts from all disciplines relevant to post-cardiac arrest care, the consensus of the scientific statement was generated and supported by three major scientific groups for emergency and critical care in post-cardiac arrest care. Results: High quality post-cardiac arrest care, including targeted temperature management, early evaluation of possible acute coronary event and intensive care for hemodynamic and respiratory care are inevitably needed to get full recovery for cardiac arrest. Management of these critical issues were reviewed and proposed in the consensus Conclusion: The goal of the statement is to provide help for the clinical physician to achieve better quality and evidence-based care in post-cardiac arrest period.