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Bi-allelic variants in ASCC1 cause the ultrarare bone fragility disorder “spinal muscular atrophy with congenital bone fractures-2” (SMABF2). However, the mechanism by which ASCC1 dysfunction leads to this musculoskeletal condition and the nature of the associated bone defect are poorly understood. By exome sequencing, we identified a novel homozygous deletion in ASCC1 in a female infant. She was born with severe muscular hypotonia, inability to breathe and swallow, and virtual absence of spontaneous movements; showed progressive brain atrophy, gracile long bones, very slender ribs, and a femur fracture; and died from respiratory failure aged 3 months. A transiliac bone sample taken postmortem revealed a distinct microstructural bone phenotype with low trabecular bone volume, low bone remodeling, disordered collagen organization, and an abnormally high bone marrow adiposity. Proteomics, RNA sequencing, and qPCR in patient-derived skin fibroblasts confirmed that ASCC1 was hardly expressed on protein and RNA levels compared with healthy controls. Furthermore, we demonstrate that mutated ASCC1 is associated with a downregulation of RUNX2, the master regulator of osteoblastogenesis, and SERPINF1, which is involved in osteoblast and adipocyte differentiation. It also exerts an inhibitory effect on TGF-b/SMAD signaling, which is important for bone development. Additionally, knockdown of ASCC1 in human mesenchymal stromal cells (hMSCs) suppressed their differentiation capacity into osteoblasts while increasing their differentiation into adipocytes. This resulted in reduced mineralization and elevated formation of lipid droplets. These findings shed light onto the pathophysiologic mechanisms underlying SMABF2 and assign a new biological role to ASCC1 acting as an important pro-osteoblastogenic and antiadipogenic regulator. [ABSTRACT FROM AUTHOR]

Background: Advanced respiratory support modalities such as non-invasive positive pressure ventilation (NiPPV) and heated and humidified high flow nasal canula (HFNC) served as useful alternatives to invasive mechanical ventilatory support for acute respiratory failure (ARF) during the peak of the SARS-CoV-2/COVID-19 pandemic. Unlike NiPPV, HFNC is a newer modality and its role in the treatment of patients with severe ARF is not yet clearly defined. Furthermore, the characteristics of responders versus non-responders to HFNC have not been determined. Although recent evidence indicates that many patients with ARF treated with HFNC survive without needing intubation, those who fail and are subsequently intubated have worse outcomes. Given that prolonged use of HFNC in patients with ARF might exacerbate patient self-inflicted lung injury, we hypothesized that among those patients with ARF due to COVID-19 pneumonia, prolonged HFNC beyond 24 h before intubation would be associated with increased in-hospital mortality. Methods: This was a retrospective, multicenter, observational cohort study of 2720 patients treated for ARF secondary to SARS-CoV-2/COVID-19 pneumonia and initially managed with HFNC within the Banner Health system during the period from March 1st, 2020, to July 31st, 2021. In the subgroup of patients for went from HFNC to IMV, we assessed the effect of the duration of HFNC prior to intubation on mortality. Results: 1392 (51%) were successfully treated with HFNC alone and 1328 (49%) failed HFNC and were intubated (HFNC to IMV). When adjusted for the covariates, HFNC duration less than 24 h prior to intubation was significantly associated with reduced mortality. Conclusions: Among patients with ARF due to COVID-19 pneumonia who fail HFNC, delay of intubation beyond 24 h is associated with increased mortality [ABSTRACT FROM AUTHOR]

Introduction: In the current era of the severe acute respiratory syndrome-coronavirus-2 epidemic, the need for respiratory care, including mechanical ventilatory (MV) management, has increased. However, there are no well-developed educational strategies for training medical personnel dealing with respiratory care in MV management. Methods: A novel mixed-methods hands-on seminar for learning MV management was conducted for the residents at Chiba University Hospital in March 2022. The seminar lasted approximately 2 hours. The learning goal for the residents was to develop skills and knowledge in performing basic respiratory care, including MV, during an outbreak of a respiratory infection. The seminar with a flipped classroom consisted of e-learning, including modules on respiratory physiology and MV management, hands-on training with a low-fidelity simulator (a lung simulator), and hands-on training with a high-fidelity simulator (a human patient simulator). The effectiveness of the seminar was evaluated using closed questions (scored on a five-point Likert scale: 1 [minimum] to 5 [maximum]) and multiple-choice questions (maximum score: 6) at the pre- and post-seminar evaluations. Results: Fourteen residents at Chiba University Hospital participated in the program. The questionnaire responses revealed that the participants' motivation for learning about MV was relatively high in the pre-seminar period (seven participants [50%] selected level 5 [very strong]), and it increased in the post-seminar period (all participants selected level 5) (p = 0.016). The responses to the multiple-choice questions revealed that the participants did not have enough knowledge to operate a mechanical ventilator, while the total score significantly improved from the pre- to post-seminar period (pre-seminar: 3.3 ± 1.1, post-seminar: 4.6 ± 1.0, p = 0.003). Conclusions: The seminar implemented in this study helped increase the residents' motivation to learn about respiratory care and improved knowledge of MV management in a short time. In particular, the flipped classroom may promote the efficiency of education on MV management. [ABSTRACT FROM AUTHOR]

Background: Traumatic pulmonary pseudocysts are a rare complication resulting from pulmonary contusion associated with blunt chest trauma. Case presentation: A 17-year-old male patient underwent emergency surgery for hemostasis of a traumatic lung injury caused by a car accident. Because the bleeding was from the peripheral lung, partial resection was performed with an automated suture machine. A routine leak test (positive pressure ventilation at 20 cm H2O) was performed as a precautionary measure. Postoperative imaging revealed rapid enlargement of a comorbid traumatic pulmonary pseudocyst. The collapse of the obliterating bronchus due to the accident and the intraoperative positive pressure ventilation for the air leak test were considered to have caused the rapid enlargement of the traumatic pulmonary pseudocyst. A thoracoscopic right lower lobectomy was performed on postoperative day 5. The patient had an uneventful postoperative course. Conclusions: To our knowledge, this is the first report of a rapidly enlarging traumatic pulmonary pseudocyst captured on preoperative and postoperative computed tomography. It would serve as a learning point for respiratory surgeons. These results suggest that when patients with traumatic pulmonary pseudocysts are operated on under general anesthesia, excessive positive pressure ventilation may cause a rapid expansion of the pulmonary pseudocyst. [ABSTRACT FROM AUTHOR]

COVID‐19, chronic obstructive pulmonary disease (COPD), heart failure (HF), and pneumonia can lead to acute respiratory deterioration. Prompt and accurate diagnosis is crucial for effective clinical management. Chest X‐ray (CXR) and chest computed tomography (CT) are commonly used for confirming the diagnosis, but they can be time‐consuming and biased. To address this, we developed a computationally efficient deep feature engineering model called Hybrid‐Patch‐Alex for automated COVID‐19, COPD, and HF diagnosis. We utilized one CXR dataset and two CT image datasets, including a newly collected dataset with four classes: COVID‐19, COPD, HF, and normal. Our model employed a hybrid patch division method, transfer learning with pre‐trained AlexNet, iterative neighborhood component analysis for feature selection, and three standard classifiers (k‐nearest neighbor, support vector machine, and artificial neural network) for automated classification. The model achieved high accuracy rates of 99.82%, 92.90%, and 97.02% on the respective datasets, using kNN and SVM classifiers. [ABSTRACT FROM AUTHOR]

BACKGROUND: Weaning from mechanical ventilation is a challenging phase of neonatal respiratory support [1]. Choosing efficient and safe noninvasive modality to prevent re-intubation and choosing the optimal time for weaning are key points for weaning success. The aim of the study is to compare the efficiency and safety of noninvasive high frequency oscillatory ventilation (NHFOV) versus noninvasive positive pressure ventilation (NIPPV) as respiratory support after extubation in preterms with respiratory distress syndrome (RDS). Also, the study compared the lung ultrasound findings between these 2 modalities and assessed the use of lung ultrasound score (LUS) as predictor for extubation outcome. METHODS: This study is a randomized controlled trial conducted on 60 preterm neonates with RDS. Patients were allocated into one of 2 groups: NIPPV or NHFOV as post-extubation noninvasive respiratory support. The 2 groups were compared regarding the incidence of extubation failure within 72 hours from extubation, oxygen needs, duration of application of the noninvasive modality, duration of admission, safety and mortality rate. LUS was assessed pre-extubation and 2 hours post-extubation. RESULTS: The study did not show a statistically significant difference in re-ventilation rate in NHFOV group (23.3%) compared to NIPPV group (30.0%), p = 0.56. Oxygen needs were significantly lower in NHFOV group compared to NIPPV groups (mean FiO2 31.8±6.09 vs 38±0.55, p = 0.007). The duration of the used noninvasive modality, CO2 concentration, LUS, and mortality rate showed statistically insignificant difference between both groups. There was a significant correlation between LUS and extubation outcome. CONCLUSION: NHFOV is a feasible noninvasive modality for respiratory support post-extubation in premature infants. LUS is a good predictor of extubation outcome in neonates. [ABSTRACT FROM AUTHOR]

A high body mass index (BMI) is a known risk factor for coronavirus infection in hospitalized patients. Our study examined the association between BMI and complications and the survival rate among COVID-19 patients. This retrospective analysis used data from a tertiary hospital in the Eastern Region of Saudi Arabia during two waves of the COVID-19 pandemic. The study included 600 participants, with the majority being between 41 and 60 years old (41.3%) and men comprising 63.5% of the sample. Approximately 42.5% of patients were obese, and 31.3% were overweight. The results showed that BMI was significantly linked to respiratory diseases (p = 0.013); end-stage renal disease (p = 0.021); and cardiovascular disease (p = 0.003) but not diabetes mellitus (p = 0.064). Death occurred in 10.8% of patients; 33.8% were admitted to the ICU; 13.8% needed mechanical ventilation; and 60.7% had lung infiltration. Obese patients with oxygen saturation levels below 93% were 2.45 times more likely to require mechanical ventilation than those in the normal-weight group. Overweight and obese patients were also more likely to require mechanical ventilation than normal-weight patients, with odds ratios of 3.66 and 2.81, respectively. The BMI categorized was not associated with survival rate in COVID-19-hospitalized patients using Kaplan-Meier survival plots (p = 0.061). However, the BMI categorized was associated with survival rate in COVID-19 ICU patients (p < 0.001). In addition, the overweight showed a statistically significant higher hazard ratio of 2.22 (p = 0.01) compared to normal-weight patients using a Cox regression model. A high BMI was identified as an independent risk factor for reduced oxygen saturation (<93%), the need for mechanical ventilation, lung infiltration, mortality, and longer ICU stays in COVID-19 patients. [ABSTRACT FROM AUTHOR]

Aims and objective. To compare the effects of Positive Pressure Ventilation (PPV) and Face Mask oxygen on arterial blood gas (ABG) parameters in children with congestive heart failure. Materials and methods. A prospective, randomized, single-blind, cross-sectional study was undertaken in eastern India’s Dr. B.C. Roy Post Graduate Institute of Pediatric Sciences PICU. From December 2014 to June 2016, single-blind randomi- zation was used to diagnose congestive heart failure in children aged 3 months to 12 years. Results. Patients receiving face mask oxygen had a mean pH of 7.2150, while those receiving NIV had a mean pH of 7.2740 (P value = 0.012, <0.05). After 6 hours, the pH improved more in the NIV group (mean pH = 7.3023) than the face mask oxygen group (mean pH = 7.2503), P value = 0.003 (<0.05). The group receiving face mask oxygen had a mean pCO2 of 54.93 at the start of the study, while the NIV group had 52.83 (P value = 0.395, >0.05). The baseline pCO2 values of the two groups were similar. After 1-2 hours of investigation, the face mask oxygen group had a mean pCO2 of 53.50, whereas the NIV group had 47.77, with a P value of 0.008 (<0.05). After 4-6 hours, the face mask oxygen group had a mean pCO2 of 50.90, while the NIV group had 46.77, with a P value of 0.001 (<0.05). Conclusion. After 6 hours of therapy, NIV improved mean pH more than face mask oxygen. NIV ventilation improved pCO2 readings more than face mask oxygen after 2 hours. The mean pCO2 drop over 4-6 hours in the NIV group was greater than in the face mask oxygen group. [ABSTRACT FROM AUTHOR]

Summary: Adequate inflation of the endotracheal tube (ETT) cuff is important to avoid leakage of anaesthetic gases or aspiration of gastric contents and to allow positive pressure ventilation. However, overinflation or herniation of the cuff can cause tracheal mucosal damage and in rare cases even obstruction of the ETT. ETT obstruction due to the cuff itself may be an underrecognised phenomenon in equine practice and we aim to create awareness with this retrospective case series (n = 3). Cases identified between 2014 and 2021 with (partial) ETT obstruction due to cuff overinflation or cuff herniation at the Utrecht University Equine Clinic were selected. Anaesthesia records were examined and presented. Two cases occurred in foals and one in a pony. In each case, high airway pressure was encountered and no or minimal thoracic excursions were visible. In all three cases, cuff deflation led to immediate normalisation of ventilation parameters. When presented with an intubated patient that is difficult to ventilate and high airway pressures exist, ETT cuff overinflation or herniation should be considered as a possible cause; rapid cuff deflation should be included in algorithms for management of ventilation failure due to suspected airway obstruction. [ABSTRACT FROM AUTHOR]

Parainfluenza virus type 3 (PIV-3) is one of the common pathogens for respiratory infections in children. Whether viral load of PIV-3 is associated with severity of respiratory diseases in children is not yet known. Our aim was to determine significance of PIV-3 viral load among infected children. We conducted a single-center, retrospective study at Tokyo Metropolitan. Children's Medical Center, Japan, from June to August 2021. Hospitalized children were screened with a posterior nasal swab for multiplex PCR, and viral load was subsequently measured from remained samples by real-time PCR. Demographic data were collected from digital charts. PIV-3 positive patients were categorized into mild group with no oxygen demand, moderate group with low-flow oxygen demand and severe group with high-flow nasal cannula oxygen or non-invasive positive pressure ventilation or mechanical ventilation. Viral loads were compared among mild, moderate and severe groups. 151 patients were positive for PIV-3. We found no statistically significant association among PIV-3 viral load and severity of respiratory diseases (p = 0.35), and no statistically significant association between severity of illness and co-detection of other viruses. In each severity group, relatively high viral load per posterior nasal swab was observed at the time of testing. Among PIV-3 patients, we could not find statistically significant between viral load and their severity, therefore we could not conclude that viral load is a good surrogate marker for clinical severity of PIV-3. [ABSTRACT FROM AUTHOR]

Background: Control of cerebral blood flow (CBF) is complex and is only beginning to be elucidated. There is paucity of information on how implementation of pneumoperitoneum and head-up tilt under general anaesthesia affects CBF. This study was designed to observe changes that occur in the internal carotid artery (ICA) blood flow with pneumoperitoneum and head-up position and corelate these changes with changes in cardiac output in patients undergoing laparoscopic cholecystectomy. Methods: ICA blood velocity and diameter was measured by Doppler ultrasound in 35 ASA grade I and II patients undergoing laparoscopic cholecystectomy, at four time points: awake, after anaesthesia induction, after induction of pneumoperitoneum, and after head-up tilt; and ICA blood flow was calculated. Simultaneously, heart rate, blood pressure, and end-tidal carbon dioxide (ETCO2) were recorded, and cardiac output was calculated. Results: ICA blood flow decreased upon anesthesia induction from 164 mL/minute to 151 ml/minute (p>0.05). ICA blood flow increased with pneumoperitoneum (from 164 mL/minute to 179ml/minute p= 0.04). Head-up tilt resulted in decrease in ICA blood flow (from 164 mL/minute to 151ml/minute, P = 0.09). Conclusion: ICA blood flow significantly increased after the creation of pneumoperitoneum in patients undergoing elective laparoscopic cholecystectomy under general anaesthesia. Induction of anaesthesia and head-up tilt, however, did not have any significant change in ICA blood flow. We suggest that ICA blood flow during anaesthesia is influenced by an interplay of actions of anaesthetic agents, positive pressure ventilation and patient position besides the changes in blood pressure, ETCO2 and cardiac output. [ABSTRACT FROM AUTHOR]

Background: Pediatric risk of mortality (PRISM III) score is used across the globe to predict the mortality of hospitalized children by an objective method based on 17 variables measured during first 24 h of admission in pediatric intensive care unit (PICU). Aims and Objectives: We have done this study to evaluate the cause, management and outcome of PICU admissions and also to find out the statistical significance of PRISM III score in predicting mortality. Materials and Methods: This observational prospective study was conducted for a period of 1 year in the PICU of a district Medical College of West Bengal among children 1-12 years age. They were divided into 4 groups according to the PRISM III scores of 1-10, 11-20, 21-30, and >30 and outcome in all the groups were recorded and analyzed. Results: Respiratory (25%), neurological (20.1%), and infectious (17.3%) etiology were major cause of PICU admission. About 17.4% patients needed mechanical ventilation, 31.2% Continuous Positive Airway Pressure and 66% patients inotropic support. Out of 144 cases, 117 discharged and 27 expired. Percentage of death is 100%, 44.4%, 21.6%, and 4.6% among child with PRISM III score of >30, 21-30, 11-21, and =10, respectively. Significant increase in mortality noted with increase in number of organ failures. Specificity and positive predictive value increases with higher PRISM III score and sensitivity and negative predictive value is more with low PRISM III score. Conclusion: PRISM III score can be used as a triage tool in limited resource settings for early initiation of intense management to high risk and salvageable cases. [ABSTRACT FROM AUTHOR]

Objectives: Diaphragmatic dysfunction has been reported as a cause of dyspnea, and its diagnosis can be made using ultrasound. Diaphragmatic ultrasound is mainly used to predict respiratory failure in chronic conditions. The use of diaphragmatic ultrasound has also risen in acute settings, such as emergency departments (EDs). However, the number of studies on its use still needs to be increased. The present study aimed to find the incidence of diaphragmatic dysfunction in the ED. Methods: This prospective cohort study was conducted in an ED. We enrolled patients aged greater than 18 years who presented with dyspnea. Diaphragmatic excursion and diaphragmatic thickness techniques were performed. The primary outcome was the incidence of diaphragmatic dysfunction. The secondary outcomes were the associations between diaphragmatic dysfunction and the composition of respiratory therapies within 24 hours, intubation within 24 hours, and 7‐day mortality. Results: A total of 237 patients were analyzed. The incidences of diaphragmatic dysfunction assessed by diaphragmatic excursion and diaphragm thickness were 22.4 and 32.1%, respectively. Patients with sepsis and cancer had the highest incidences. Diaphragmatic dysfunction assessed by both techniques was not associated with the composition of respiratory support therapies within 24 hours, intubation within 24 hours, or 7‐day mortality. Conclusions: The incidence of diaphragmatic dysfunction in dyspneic patients in the ED ranged from 22.4 to 32.1%, depending on the ultrasound technique. Diaphragmatic dysfunction was not associated with the composition of respiratory support therapies, intubation, or mortality. [ABSTRACT FROM AUTHOR]

Bronchopulmonary dysplasia (BPD), a disorder characterized by arrested lung development, is a frequent cause of morbidity and mortality in premature infants. Parenchymal lung changes in BPD are relatively well-characterized and highly studied; however, there has been less emphasis placed on the role that airways disease plays in the pathophysiology of BPD. In preterm infants born between 22 and 32 weeks gestation, the conducting airways are fully formed but still immature and therefore susceptible to injury and further disruption of development. The arrest of maturation results in more compliant airways that are more susceptible to deformation and damage. Consequently, neonates with BPD are prone to developing airway pathology, particularly for patients who require intubation and positive-pressure ventilation. Airway pathology, which can be divided into large and small airways disease, results in increased respiratory morbidity in neonates with chronic lung disease of prematurity. [ABSTRACT FROM AUTHOR]

Background: Newborn resuscitation guidelines recommend positive pressure ventilation (PPV) for newborns who do not establish effective spontaneous breathing after birth. T-piece resuscitator systems are commonly used in high-resource settings and can additionally provide positive end-expiratory pressure (PEEP). Short expiratory time, high resistance, rapid dynamic changes in lung compliance and large tidal volumes increase the possibility of incomplete exhalation. Previous publications indicate that this may occur during newborn resuscitation. Our aim was to study examples of incomplete exhalations in term newborn resuscitation and discuss these against the theoretical background. Methods: Examples of flow and pressure data from respiratory function monitors (RFM) were selected from 129 term newborns who received PPV using a T-piece resuscitator. RFM data were not presented to the user during resuscitation. Results: Examples of incomplete exhalation with higher-than-set PEEP-levels were present in the recordings with visual correlation to factors affecting time needed to complete exhalation. Conclusions: Incomplete exhalation and the relationship to expiratory time constants have been well described theoretically. We documented examples of incomplete exhalations with increased PEEP-levels during resuscitation of term newborns. We conclude that RFM data from resuscitations can be reviewed for this purpose and that incomplete exhalations should be further explored, as the clinical benefit or risk of harm are not known. [ABSTRACT FROM AUTHOR]

Background: European guidelines recommend the use of pulse oximetry (PO) during newborn resuscitation, especially when there is a need for positive pressure ventilation or supplemental oxygen. The objective was to evaluate (i) to what extent PO was used, (ii) the time and resources spent on the application of PO, and (iii) the proportion of time with a useful PO signal during newborn resuscitation. Methods: A prospective observational study was conducted at Stavanger University Hospital, Norway, between 6 June 2019 and 16 November 2021. Newborn resuscitations were video recorded, and the use of PO during the first ten minutes of resuscitation was recorded and analysed. Results: Of 7466 enrolled newborns, 289 (3.9%) received ventilation at birth. The resuscitation was captured on video in 230 cases, and these newborns were included in the analysis. PO was applied in 222 of 230 (97%) newborns, median (quartiles) 60 (24, 58) seconds after placement on the resuscitation table. The proportion of time used on application and adjustments of PO during ongoing ventilation and during the first ten minutes on the resuscitation table was 30% and 17%, respectively. Median two healthcare providers were involved in the PO application. Video of the PO monitor signal was available in 118 (53%) of the 222 newborns. The proportion of time with a useful PO signal during ventilation and during the first ten minutes on the resuscitation table was 5% and 35%, respectively. Conclusion: In total, 97% of resuscitated newborns had PO applied, in line with resuscitation guidelines. However, the application of PO was time-consuming, and a PO signal was only obtained 5% of the time during positive pressure ventilation. [ABSTRACT FROM AUTHOR]

This article explores the roles of anaesthetists in positioning surgical patients. Patient positioning is crucial for surgical access and patient safety, and anaesthetists play a vital role in maintaining physiological stability during positioning. The study emphasizes the importance of teamwork and communication among the surgical team in patient positioning. Challenges include the risk of nerve injury, maintaining respiratory function, and preventing pressure-related injuries. Clear guidelines and protocols, as well as standardized checklists, are recommended to enhance patient safety. Overall, anaesthetists play a critical role in balancing surgical needs with patient safety during positioning. [Extracted from the article]

This article discusses the variation in the amount of leakage containing inhalational anaesthetics in the breathing circuits of anaesthesia machines. The authors challenge the claim made by Mulier et al. that leak is constant, arguing that the amount of leak is actually proportional to the pressure difference between the interior and exterior of the breathing circuit. They conducted an experiment using a high-fidelity simulator and found that leaks seldom occur during low-flow anaesthesia if the leak level is below 300 ml.min-1. They also note that modern anaesthesia machines with automatic leak testing and pressure-regulated ventilation modes should have negligible system leaks. [Extracted from the article]

This article discusses the use of mask ventilation and oxygen supplementation in German delivery rooms from 2008 to 2022. The study analyzed data on perinatal health in Germany and found that the frequency of mask ventilation increased significantly during this time period, while the use of supplementary oxygen decreased. The proportion of preterm births also decreased. The findings suggest that more infants have been born in a poor clinical condition in Germany, despite the decrease in preterm births. The study highlights the importance of appropriate training in mask ventilation for healthcare professionals. Further research is needed to determine which neonates require resuscitative interventions and why. [Extracted from the article]

The article comments on a study which evaluated the effect of aerosol delivery efficiency of different intrapulmonary percussive ventilation (IPV) settings and lung conditions. It summarizes findings on drug delivery efficiency via IPV attached to an endotracheal tube/breathing simulator and connected to an in-line adapter superimposed to a model of pressure controlled continuous mandatory ventilation mechanical ventilation. It emphasizes the need to monitor patients while using in-line IPV.

The article discusses the potential impact of lack of blinding on objective outcomes in trials on neonatal ventilation. The authors argue that blinding has been underestimated in systematic reviews, leading to unjustified downgrading of the certainty of evidence. They suggest that objective outcomes should not be downgraded due to lack of blinding, but the authors of the article disagree, stating that non-blinding can influence patient management and assessment. They also highlight the importance of standardized intervention strategies in trial protocols to address biases caused by lack of blinding. [Extracted from the article]

This document is a response to a letter to the editor regarding non-invasive intracranial pressure analysis in craniosynostosis. The authors address the comments and suggest the use of a non-invasive intracranial pressure monitor for individuals with craniosynostosis. They conducted a pilot project using this device and retinography to monitor craniosynostosis patients. The authors acknowledge the limitations of their study and discuss the statistical methods used. They also mention future research considerations and express gratitude for the opportunity to contribute to the discussion on non-invasive methods of intracranial pressure assessment for individuals with craniosynostosis. [Extracted from the article]

The article discusses the effectiveness of home nocturnal noninvasive ventilation (NIV) for patients with chronic hypoxic respiratory failure (CHRF) due to chronic obstructive pulmonary disease (COPD), highlighting that initiating home NIV in outpatient settings significantly reduces mortality and hospitalizations.

Traumatic diaphragmatic hernia is relatively uncommon and occurs most commonly after a road traffic accident (5%). Diaphragmatic rupture is mostly associated with vital organ injuries such as the liver, spleen, lungs, bones, pelvis, and brain, which can be severely damaged. The anaesthetic management of a patient presenting with traumatic diaphragmatic hernia depends on any associated vital organ injuries. Hereby, the author present a case series of three patients with traumatic diaphragmatic hernia with different presentations managed accordingly. In the first case, a 37-year-old male presented with diaphragmatic hernia and cervical spine fracture following a road traffic accident. Awake fibreoptic intubation was performed with utmost care to avoid further injury to the cervical spine. After intubation, positive pressure ventilation was given with low tidal volume to avoid barotrauma and to expand the atelectatic lung. The second case involved a 48-year-old male with a history of falling from a height one week prior, who presented with right-sided diaphragmatic rupture and a liver contusion. Intubation was performed using a left-sided double-lumen tube, and one-lung ventilation was applied to facilitate thoracotomy. A thoracic paravertebral block was administered to alleviate postoperative pain, providing good pain relief. In the third case, a 56-year-old male with a known case of Chronic Obstructive Pulmonary Disease (COPD) presented to the hospital following a road traffic accident. The patient had lung contusion and haemopneumothorax with poor pulmonary reserve, and required emergency surgical repair. Combined spinal-epidural anaesthesia was preferred over general anaesthesia, as intubation may cause bronchospasm and life-threatening complications in COPD patients. [ABSTRACT FROM AUTHOR]

Background: Approximately nine million adults in the United States are living with chronic obstructive pulmonary disease (COPD), and positive associations between short-term air pollution exposure and increased risk of COPD hospitalizations in older adults are consistently reported. We examined the association between short-term PM2.5 exposure and hospitalizations and assessed if there is modification by long-term exposure in a cohort of individuals with COPD. Methods: In a time-referent case-crossover design, we used a cohort of randomly selected individuals with electronic health records from the University of North Carolina Healthcare System, restricted to patients with a medical encounter coded with a COPD diagnosis from 2004–2016 (n = 520), and estimated ambient PM2.5 concentrations from an ensemble model. Odds ratios and 95% confidence intervals (OR (95%CI)) were estimated with conditional logistic regression for respiratory-related, cardiovascular (CVD), and all-cause hospitalizations. Exposures examined were 0–2 and 0–3 day lags of PM2.5 concentration, adjusting for daily census-tract temperature and humidity, and models were stratified by long-term (annual average) PM2.5 concentration at the median value. Results: We observed generally null or low-magnitude negative associations with short-term PM2.5 exposure and respiratory-related (OR per 5 µg/m3 increase in 3-day lag PM2.5: 0.971 (0.885, 1.066)), CVD (2-day lag: 0.976 (0.900, 1.058) and all-cause (3 day lag: 1.003 (0.927, 1.086)) hospitalizations. Associations between short-term PM2.5 exposure and hospitalizations were higher among patients residing in areas with higher levels of annual PM2.5 concentrations (OR per 5 µg/m3 in 3-day lag PM2.5 for all-cause hospitalizations: 1.066 (0.958, 1.185)) than those in areas with lower annual PM2.5 concentrations (OR per 5 µg/m3 in 3-day lag PM2.5 for all-cause hospitalizations: 0.914 (0.804, 1.039)). Concluisons: Differences in associations demonstrate that people in areas with higher annual PM2.5 exposure may be associated with higher risk of hospitalization during short-term increases in PM2.5 exposure. [ABSTRACT FROM AUTHOR]

The measurement of physiologic pressure helps diagnose and prevent associated health complications. From typical conventional methods to more complicated modalities, such as the estimation of intracranial pressures, numerous invasive and noninvasive tools that provide us with insight into daily physiology and aid in understanding pathology are within our grasp. Currently, our standards for estimating vital pressures, including continuous BP measurements, pulmonary capillary wedge pressures, and hepatic portal gradients, involve the use of invasive modalities. As an emerging field in medical technology, artificial intelligence (AI) has been incorporated into analyzing and predicting patterns of physiologic pressures. AI has been used to construct models that have clinical applicability both in hospital settings and at-home settings for ease of use for patients. Studies applying AI to each of these compartmental pressures were searched and shortlisted for thorough assessment and review. There are several AI-based innovations in noninvasive blood pressure estimation based on imaging, auscultation, oscillometry and wearable technology employing biosignals. The purpose of this review is to provide an in-depth assessment of the involved physiologies, prevailing methodologies and emerging technologies incorporating AI in clinical practice for each type of compartmental pressure measurement. We also bring to the forefront AI-based noninvasive estimation techniques for physiologic pressure based on microwave systems that have promising potential for clinical practice. [ABSTRACT FROM AUTHOR]

The article offers information on airway management in neonatal patients, emphasizing the importance of effective techniques in ensuring adequate ventilation. Topics include the common causes of cardiac arrest in neonates, the challenges of face mask ventilation, and a study investigating the impact of positioning strategies on positive pressure ventilation (PPV).

Purpose: There is an elevated incidence of hypoxemia during the airway management of the morbidly obese. We aimed to assess whether optimizing body position and ventilation during pre-oxygenation allow a longer safe non-hypoxic apnea period (SNHAP). Methods: Fifty morbidly obese patients were recruited and randomized for this study. Patients were positioned and preoxygenated for three minutes in the ramp position associated with spontaneous breathing without additional CPAP or PEEP (RP/ZEEP group) or in the reverse Trendelenburg position associated with pressure support ventilation mode with pressure support of 8 cmH2O and an additional 10 cmH2O of PEEP while breathing spontaneously (RT/PPV group) according to randomization. Results: The SNHAP was significantly longer in the RT/PPV group (258.2 (55.1) vs. 216.7 (42.3) seconds, p = 0.005). The RT/PPV group was also associated to a shorter time to obtain a fractional end-tidal oxygen concentration (FEtO2) of 0.90 (85.1(47.8) vs 145.3(40.8) seconds, p < 0.0001), a higher proportion of patients that reached the satisfactory FEtO2 of 0.90 (21/24, 88% vs. 13/24, 54%, p = 0.024), a higher FEtO2 during preoxygenation (0.91(0.05) vs. 0.89(0.01), p = 0.003) and a faster return to 97% oxygen saturation after ventilation resumption (69.8 (24.2) vs. 91.4 (39.2) seconds, p = 0.038). Conclusion: In the morbidly obese population, RT/PPV, compared to RP/ZEEP, lengthens the SNHAP, decreases the time to obtain optimal preoxygenation conditions, and allows a faster resuming of secure oxygen saturation. The former combination allows a more significant margin of time for endotracheal intubation and minimizes the risk of hypoxemia in this highly vulnerable population. Trial registration: NCT02590406, 29/10/2015. [ABSTRACT FROM AUTHOR]

Simple Summary: This study analyzed data from the National COVID Cohort Collaborative, the largest US COVID-19 database, to determine if an association exists between COVID-19 and blood levels of high-density lipoprotein, and high-density lipoprotein's main protein component, apolipoprotein A1. Our findings suggest that individuals with higher levels of high-density lipoprotein and apolipoprotein A1 were less likely to be infected with SARS-CoV-2 and were less likely to develop severe COVID-19 requiring hospitalization or invasive medical interventions. They were also less likely to develop acute kidney injury. On the other hand, the presence of underlying health issues (comorbidities) increased the risk of developing severe COVID-19 and acute kidney injury. African American and Hispanic populations were more likely to experience severe disease, while smoking and being male appeared to reduce the incidence of infection but increased the risk of developing severe disease and acute kidney injury. This study is the first to explore the association of high-density lipoprotein and apolipoprotein A1 with COVID-19 outcomes using US population data. This study analyzed data from the National COVID Cohort Collaborative (N3C) database to investigate whether high-density lipoprotein (HDL) and its major protein component, apolipoprotein A1 (apoA1), are associated with severe COVID-19 sequelae, specifically acute kidney injury (AKI) and severe COVID-19 disease as defined by the infection resulting in hospitalization, extracorporeal membrane oxygenation (ECMO), invasive ventilation, or death. Our study included a total of 1,415,302 subjects with HDL values and 3589 subjects with apoA1 values. Higher levels of both HDL and apoA1 were associated with a lower incidence of infection as well as a lower incidence of severe disease. Higher HDL levels were also associated with a lower incidence of developing AKI. Most comorbidities were negatively correlated with SARS-CoV-2 infection, presumably due to the behavioral changes that occurred as a result of the precautions taken by individuals with underlying comorbidities. The presence of comorbidities, however, was associated with developing severe COVID-19 disease and AKI. African American and Hispanic populations experienced worse outcomes, including a higher incidence of infection and the development of severe disease, as well as AKI. Smoking and being male were associated with a lower incidence of infection, while they were risk factors for the development of severe disease and AKI. The results on cholesterol and diabetes drugs warrant further research, given that the database included multiple drugs in each category impeding for analysis of specific medications. Despite the current limitations in the N3C data, this study is the first to investigate the roles of HDL and apoA1 on the outcomes of COVID-19 using the US population data. [ABSTRACT FROM AUTHOR]

Ventilation with positive end-expiratory pressure (PEEP) may result in decreased venous return to the heart and therefore decrease cardiac output. We evaluated the influence of PEEP ventilation on arterial blood pressure in the field in 296 posttraumatic intubated patients being treated by a helicopter emergency medical service in a retrospective cohort study. Initial systolic blood pressure on the scene, upon hospital admission and their mean difference were compared between patients being ventilated with no/low PEEP (0–0.3 kPa) and moderate PEEP (0.3–1 kPa). In a subgroup analysis of initially hemodynamic unstable patients (systolic blood pressure < 80 mmHg), systolic blood pressure was compared between patients being ventilated with no/low or moderate PEEP Further, the mean difference between initial systolic blood pressure and upon hospital admission was correlated with the chosen PEEP. Systolic arterial blood pressure of patients being ventilated with no/low PEEP improved from 105 ± 36 mmHg to 112 ± 38 mmHg, and that of patients being ventilated with moderate PEEP improved from 105 ± 38 mmHg to 119 ± 27 mmHg. In initially unstable patients being ventilated with no/low PEEP systolic blood pressure improved from initially 55 ± 36 mmHg to 78 ± 30 mmHg upon hospital admission, and in those being ventilated with moderate PEEP, the systolic blood pressure improved from 43 ± 38 mmHg to 91 ± 27 mmHg. There was no significant correlation between the chosen PEEP and the mean difference of systolic blood pressure (Pearson's correlation, r = 0.07, P = 0.17). Ventilation with moderate PEEP has no adverse effect on arterial systolic blood pressure in this cohort of trauma patients requiring mechanical ventilation. Initially unstable patients being ventilated with moderate PEEP tend to be hemodynamically more stable. [ABSTRACT FROM AUTHOR]

The article discuss the challenges and strategies for managing chronic lung disease (CLD) in premature infants. It emphasizes the importance of lung-protective ventilation techniques in preventing moderate to severe CLD in infants born at or after 25 weeks post-menstrual age (PMA). It further highlights the characteristics of CLD, including dysplastic changes in the lungs and airways that reduce their normal function.

Aim: International Liaison Committee on Resuscitation (ILCOR‐2020) report recommend starting delivery room resuscitation of all preterm neonates of <35 weeks' gestation with 21–30% oxygen. However, the correct initial oxygen concentration for resuscitation of preterm neonates in delivery room is inconclusive. In this blinded, randomised, controlled trial, we compared room air with 100% oxygen for oxidative stress and clinical outcomes in delivery room resuscitation of preterm neonates. Methods: Preterm neonates 28–33 weeks' gestation requiring positive pressure ventilation at birth were randomly allocated to room air or 100% oxygen. Investigators, outcome assessors and data analysts were blinded. Rescue 100% oxygen was used whenever trial gas failed (need for positive pressure ventilation >60 s or chest compression). Primary outcome: Plasma 8‐isoprostane levels at 4 h of age. Secondary outcomes: mortality by discharge, bronchopulmonary dysplasia, retinopathy of prematurity and neurological status at 40 weeks post‐menstrual age. All subjects were followed till discharge. Intention to treat analysis was carried out. Results: A total of 124 neonates were randomised to room air (n = 59) or 100% oxygen (n = 65). Isoprostane level at 4 h was similar in both the groups (median (interquartile range): 280 (180–430) vs. 250 (173–360) pg/mL, P = 0.47). No difference was observed in mortality and other clinical outcomes. Room air group had higher treatment failures (27 (46%) vs. 16 (25%); relative risk (RR) 1.9 (1.1–3.1)) and took longer time to establish regular respiration (230 ± 231 vs. 182 ± 261, mean difference = 48 (40, 136) seconds). Conclusions: In preterm neonates 28–33 weeks' gestation requiring resuscitation in the delivery room, room air (21%) is not the correct concentration to initiate resuscitation. Larger controlled trials involving multiple centres in low‐ and middle‐income countries are immediately required for a conclusive answer. [ABSTRACT FROM AUTHOR]

Background: Pulse amplitude index (PAx), a descriptor of cerebrovascular reactivity, correlates the changes of the pulse amplitude of the intracranial pressure (ICP) waveform (AMP) with changes in mean arterial pressure (MAP). AMP relies on cerebrovascular compliance, which is modulated by the state of the cerebrovascular reactivity. PAx can aid in prognostication after acute brain injuries as a tool for the assessment of cerebral autoregulation and could potentially tailor individual management; however, invasive measurements are required for its calculation. Our aim was to evaluate the relationship between noninvasive PAx (nPAx) derived from a novel noninvasive device for ICP monitoring and PAx derived from gold standard invasive methods. Methods: We retrospectively analyzed invasive ICP (external ventricular drain) and non-invasive ICP (nICP), via mechanical extensometer (Brain4Care Corp.). Invasive and non-invasive ICP waveform morphology data was collected in adult patients with brain injury with arterial blood pressure monitoring. The time series from all signals were first treated to remove movement artifacts. PAx and nPAx were calculated as the moving correlation coefficients of 10-s averages of AMP or non-invasive AMP (nAMP) and MAP. AMP/nAMP was determined by calculating the fundamental frequency amplitude of the ICP/nICP signal over a 10-s window, updated every 10-s. We then evaluated the relationship between invasive PAx and noninvasive nPAx using the methods of repeated-measures analysis to generate an estimate of the correlation coefficient and its 95% confidence interval (CI). The agreement between the two methods was assessed using the Bland–Altman test. Results: Twenty-four patients were identified. The median age was 53.5 years (interquartile range 40–70), and intracranial hemorrhage (84%) was the most common etiology. Twenty-one (87.5%) patients underwent mechanical ventilation, and 60% were sedated with a median Glasgow Coma Scale score of 8 (7–15). Mean PAx was 0.0296 ± 0.331, and nPAx was 0.0171 ± 0.332. The correlation between PAx and nPAx was strong (R = 0.70, p < 0.0005, 95% CI 0.687–0.717). Bland–Altman analysis showed excellent agreement, with a bias of − 0.018 (95% CI − 0.026 to − 0.01) and a localized regression trend line that did not deviate from 0. Conclusions: PAx can be calculated by conventional and noninvasive ICP monitoring in a statistically significant evaluation with strong agreement. Further study of the applications of this clinical tool is warranted, with the goal of early therapeutic intervention to improve neurologic outcomes following acute brain injuries. [ABSTRACT FROM AUTHOR]

Since traditional non-contact normal vector correction schemes cannot perform well on thin panels with weak rigidity, traditional normal vector correction schemes are studied based on the contact-type pressure foot structure, and a two-point correction algorithm suitable for this structure is proposed. A calibration method for the contact-type pressure foot’s normal vector measurement system is designed. Since the elastic deformation on thin panels with weak rigidity under unidirectional pressure can impact the hole position accuracy, a tool center point (TCP) displacement compensation technology is proposed. This technology uses laser displacement sensors to monitor the amount of panels’ setback and dynamically adjusts the TCP position before normal vector correction, thereby achieving real-time compensation for panels’ setback. The test platform is built and the hole-making test verifies that the contact-type normal vector correction technology and the TCP displacement compensation technology could effectively ensure the perpendicularity and position accuracy of holes. The perpendicularity error of holes is less than 0.25° and the position deviation is less than 0.4 mm. [ABSTRACT FROM AUTHOR]

Endotracheal intubation revolutionized anesthesia and allowed prolonged surgical procedures to be performed. It also made positive pressure ventilation possible in patients in respiratory insufficiency and being managed in intensive care units. But successful intubation required the development of laryngoscopes. A variety of blades were developed to be used in different sets of patients. A laryngoscope came to be known as a symbol of the specialty of anesthesiology. But it was not always safe, nor successful, necessitating more sophisticated instruments. Video laryngoscopes were introduced with a sigh of relief for the anesthesiologists in difficult airway cases. Many variations of video laryngoscopes with slight differences have been marketed. But cases of video laryngoscope related injuries have been reported. This paper gives an over-view of the possible mechanism and preventive measures. [ABSTRACT FROM AUTHOR]

Introduction The effect of remdesivir on COVID-19 mortality remains conflicting. Elderly individuals are at risk for poor COVID-19 outcomes. We aimed to assess the effect of remdesivir on COVID-19 mortality among elderly individuals, using real-world data. Methods Retrospective multinational cohort of individuals aged ≥65 years, hospitalized with COVID-19 in six medical centres between January 2020 and May 2021. Associations with in-hospital mortality were evaluated using a multivariable logistic regression model with propensity score adjustment for remdesivir therapy and while implementing generalized estimating equations to control for centre effect. Sensitivity analysis was performed by stratification according to the degree of respiratory support. Results Of 3010 individuals included, 2788 individuals required either oxygen supplementation or non-invasive/invasive mechanical ventilation, 489 (16%) were treated with remdesivir, and 836 (28%) died. Median age was 77 (IQR 70–84) years and 42% were women. Remdesivir was the only therapeutic intervention associated with decreased mortality [adjusted OR (aOR) 0.49, 95% CI 0.37–0.66, P  < 0.001]. This protective effect was shown for individuals requiring oxygen support and non-invasive mechanical ventilation, while no association was found among individuals necessitating invasive mechanical ventilation. Risk factors for mortality included invasive ventilation (aOR 5.18, 95% CI 2.46–10.91, P  < 0.001), higher serum creatinine (aOR 1.25, 95% CI 1.09–1.43, P  = 0.001) and dyspnoea (aOR 1.40, 95% CI 1.07–1.84, P  = 0.015) on presentation, and other non-modifiable factors, such as comorbidities. Conclusions Among elderly individuals hospitalized with COVID-19, remdesivir carries survival benefit for those with moderate to severe disease. Its role among individuals with critical illness should be further assessed. [ABSTRACT FROM AUTHOR]

Introduction: The clinical features of COVID-19 are highly variable. It has been speculated that the progression across COVID-19 may be triggered by excessive inspiratory drive activation. The aim of the present study was to assess whether the tidal swing in central venous pressure (ΔCVP) is a reliable estimate of inspiratory effort. Methods: Thirty critically ill patients with COVID-19 ARDS underwent a PEEP trial (0–5–10 cmH2O) during helmet CPAP. Esophageal (ΔPes) and transdiaphragmatic (ΔPdi) pressure swings were measured as indices of inspiratory effort. ΔCVP was assessed via a standard venous catheter. A low and a high inspiratory effort were defined as ΔPes ≤ 10 and  >15 cmH2O, respectively. Results: During the PEEP trial, no significant changes in ΔPes (11 [6–16] vs. 11 [7–15] vs. 12 [8–16] cmH2O, p = 0.652) and in ΔCVP (12 [7–17] vs. 11.5 [7–16] vs. 11.5 [8–15] cmH2O, p = 0.918) were detected. ΔCVP was significantly associated with ΔPes (marginal R2 0.87, p < 0.001). ΔCVP recognized both low (AUC-ROC curve 0.89 [0.84–0.96]) and high inspiratory efforts (AUC-ROC curve 0.98 [0.96–1]). Conclusions: ΔCVP is an easily available a reliable surrogate of ΔPes and can detect a low or a high inspiratory effort. This study provides a useful bedside tool to monitor the inspiratory effort of spontaneously breathing COVID-19 patients. [ABSTRACT FROM AUTHOR]

Objective: Endotracheal intubation is a common procedure in the medical intensive care unit (MICU), but it carries risk of complications including, but not limited to, subglottic stenosis (SGS) and tracheal stenosis (TS). Current literature suggests identifiable risk factors for the development of airway complications. This study is a comprehensive evaluation of potential risk factors in patients who developed SGS and TS following endotracheal intubation in our MICU. Methods: Patients intubated in our MICU were identified from 2013 to 2019. Diagnoses of SGS or TS within 1 year of MICU admission were identified. Data extracted included age, sex, body measurements, comorbidities, bronchoscopies, endotracheal tube size, tracheostomy, social history, and medications. Patients with prior diagnosis of airway complication, tracheostomy, or head and neck cancer were excluded. Univariate and multivariate logistic regressions were performed. Results: A total of 136 patients with TS or SGS were identified out of a sample of 6603 patients intubated in the MICU. Cases were matched to controls who did not develop airway stenosis based on identical Charlson Comorbidity Index scores. Eighty six controls were identified with a complete record of endotracheal/tracheostomy tube size, airway procedures, sociodemographic data, and medical diagnosis. Regression analysis showed that SGS or TS were associated with tracheostomy, bronchoscopy, chronic obstructive pulmonary disease, current tobacco use, gastroesophageal reflux disease, systemic lupus erythematosus, pneumonia, bronchitis, and numerous medication classes. Conclusion: Various conditions, procedures, and medications are associated with an increased risk of developing SGS or TS. Level of evidence: 4. This study evaluates risk factors for the development of subglottic stenosis and tracheal stenosis for adult patients who underwent endotracheal intubation in the medical intensive care unit at a tertiary care referral hospital. [ABSTRACT FROM AUTHOR]

Right ventricular (RV) adaptation is the principal determinant of outcomes in pulmonary arterial hypertension (PAH), however, RV function is challenging to assess. RV responses to hemodynamic stressors are particularly difficult to interrogate without invasive testing. This study sought to identify metabolomic markers of in vivo right ventricular function and exercise performance in PAH. Consecutive subjects with PAH (n = 23) underwent rest and exercise right heart catheterization with multibeat pressure volume loop analysis. Pulmonary arterial blood was collected at rest and during exercise. Mass spectrometry-based targeted metabolomics were performed, and metabolic associations with hemodynamics and comprehensive measures of RV function were determined using sparse partial least squares regression. Metabolite profiles were compared with N-terminal prohormone of B-type natriuretic peptide (NT-proBNP) measurements for accuracy in modeling ventriculo-arterial parameters. Thirteen metabolites changed in abundance with exercise, including metabolites reflecting increased arginine bioavailability, precursors of catecholamine and nucleotide synthesis, and branched-chain amino acids. Higher resting arginine bioavailability predicted more favorable exercise hemodynamics and pressure-flow relationships. Subjects with more severe PAH augmented arginine bioavailability with exercise to a greater extent than subjects with less severe PAH. We identified relationships between kynurenine pathway metabolism and impaired ventriculo-arterial coupling, worse RV diastolic function, lower RV contractility, diminished RV contractility with exercise, and RV dilation with exercise. Metabolite profiles outperformed NT-proBNP in modeling RV contractility, diastolic function, and exercise performance. Specific metabolite profiles correspond to RV functional measurements only obtainable via invasive pressure-volume loop analysis and predict RV responses to exercise. Metabolic profiling may inform discovery of RV functional biomarkers. [ABSTRACT FROM AUTHOR]

Obstructive sleep apnea (OSA) is characterized by repetitive episodes of disrupted breathing during sleep. The most effective treatment for OSA is positive pressure ventilation; however, this treatment can be complicated by adherence difficulties. An array of alternative OSA therapies have emerged, including positional therapy, nasal exhalation devices, oral appliances, and various nasal, pharyngeal, and skeletal surgical treatments. One of the newest options, hypoglossal nerve stimulation (HNS) therapy, represents a hybrid medical and surgical treatment. This therapy involves an FDA-approved surgically implanted neuromodulation system that is activated by the patient each night to augment upper airway dilator muscle activity and improve airflow. The implanted components comprise a pulse generator, an electrode on the distal portion of the hypoglossal nerve, and a respiratory sensing lead that allows for synchronization of electrical impulses with the patient’s respiratory cycle. Using a representative patient case, the authors describe HNS therapy, including its indications, patient selection, surgical procedure, long-term outpatient management, and outcomes data. [ABSTRACT FROM AUTHOR]

A key unresolved controversy in severe COVID-19 pneumonitis in pregnancy is the optimum timing of delivery and whether delivery improves or worsens maternal outcomes. We aimed to assess clinical data on every intensive care unit (ICU) day for pregnant and postpartum women admitted to the ICU with COVID-19, with a particular focus on the days preceding and following delivery. In this multicentre, nationwide, prospective and retrospective cohort study, we evaluated all pregnant women who were admitted to an ICU in Israel with severe COVID-19 pneumonitis from the 13th week of gestation to the 1st week postpartum. We excluded pregnant patients in which the ICU admission was unrelated to severe COVID-19 pneumonitis. We assessed maternal and neonatal outcomes and longitudinal clinical and laboratory ICU data. The primary overall outcome was maternal outcome (worst of the following: no invasive positive pressure ventilation [IPPV], use of IPPV, use of extracorporeal membrane oxygenation [ECMO], or death). The primary longitudinal outcome was Sequential Organ Failure Assessment (SOFA) score, and the secondary longitudinal outcome was the novel PORCH (positive end-expiratory pressure [PEEP], oxygenation, respiratory support, chest x-ray, haemodynamic support) score. Patients were classified into four groups: no-delivery (pregnant at admission and no delivery during the ICU stay), postpartum (ICU admission ≥1 day after delivery), delivery-critical (pregnant at admission and receiving or at high risk of requiring IPPV at the time of delivery), or delivery-non-critical (pregnant at admission and not critically ill at the time of delivery). From Feb 1, 2020, to Jan 31, 2022, 84 patients were analysed: 34 patients in the no-delivery group, four in postpartum, 32 in delivery-critical, and 14 in delivery-non-critical. The delivery-critical and postpartum groups had worse outcomes than the other groups: 26 (81%) of 32 patients in the delivery-critical group and four (100%) of four patients in the postpartum group required IPPV; 12 (38%) and three (75%) patients required ECMO, and one (3%) and two (50%) patients died, respectively. The delivery-non-critical and no-delivery groups had far better outcomes than other groups: six (18%) of 34 patients and two (14%) of 14 patients required IPPV, respectively; no patients required ECMO or died. Oxygen saturation (SpO 2), SpO 2 to fraction of inspired oxygen (FiO 2) ratio (S/F ratio), partial pressure of arterial oxygen to FiO 2 ratio (P/F ratio), ROX index (S/F ratio divided by respiratory rate), and SOFA and PORCH scores were all highly predictive for adverse maternal outcome (p<0·0001). The delivery-critical group deteriorated on the day of delivery, continued to deteriorate throughout the ICU stay, and took longer to recover (ICU duration, Mantel-Cox p<0·0001), whereas the delivery-non-critical group improved rapidly following delivery. The day of delivery was a significant covariate for PORCH (p<0·0001) but not SOFA (p=0·09) scores. In patients who underwent delivery during their ICU stay, maternal outcome deteriorated following delivery among those defined as critical compared with non-critical patients, who improved following delivery. Interventional delivery should be considered for maternal indications before patients deteriorate and require mechanical ventilation. None. [ABSTRACT FROM AUTHOR]

Lung recruitment maneuvers following one-lung ventilation (OLV) increase the risk for the development of acute lung injury. The application of continuous negative extrathoracic pressure (CNEP) is gaining interest both in intubated and non-intubated patients. However, there is still a lack of knowledge on the ability of CNEP support to recruit whole lung atelectasis following OLV. We investigated the effects of CNEP following OLV on lung expansion, gas exchange, and hemodynamics. Ten pigs were anesthetized and mechanically ventilated with pressure-regulated volume control mode (PRVC; FiO2: 0.5, Fr: 30–35/min, VT: 7 mL/kg, PEEP: 5 cmH2O) for 1 hour, then baseline (BL) data for gas exchange (arterial partial pressure of oxygen, PaO2; and carbon dioxide, PaCO2), ventilation and hemodynamical parameters and lung aeration by electrical impedance tomography were recorded. Subsequently, an endobronchial blocker was inserted, and OLV was applied with a reduced VT of 5 mL/kg. Following a new set of measurements after 1 h of OLV, two-lung ventilation was re-established, combining PRVC (VT: 7 mL/kg) and CNEP (−15 cmH2O) without any hyperinflation maneuver and data collection was then repeated at 5 min and 1 h. Compared to OLV, significant increases in PaO2 (154.1 ± 13.3 vs. 173.8 ± 22.1) and decreases in PaCO2 (52.6 ± 11.7 vs. 40.3 ± 4.5 mmHg, p < 0.05 for both) were observed 5 minutes following initiation of CNEP, and these benefits in gas exchange remained after an hour of CNEP. Gradual improvements in lung aeration in the non-collapsed lung were also detected by electrical impedance tomography (p < 0.05) after 5 and 60 min of CNEP. Hemodynamics and ventilation parameters remained stable under CNEP. Application of CNEP in the presence of whole lung atelectasis proved to be efficient in improving gas exchange via recruiting the lung without excessive airway pressures. These benefits of combined CNEP and positive pressure ventilation may have particular value in relieving atelectasis in the postoperative period of surgical procedures requiring OLV. [ABSTRACT FROM AUTHOR]

Historically, the oro-nasal mask has been the preferred interface to deliver Non-Invasive Positive Pressure Ventilation (NPPV) in critically ill patients. To overcome the problems related to air leaks and discomfort, Total Full-face masks have been designed. No study has comparatively evaluated the performance of the total Full-face masks available.The aim of this bench study was to evaluate the influence of three largely diffuse models of total Full -face masks on patient-ventilator synchrony and performance during pressure support ventilation. NPPV was applied to a mannequin, connected to an active test lung through three largely diffuse Full-face masks: Dimar Full-face mask (DFFM), Performax Full-face mask (RFFM) and Pulmodyne Full-face mask (PFFM).The performance analysis showed that the ΔPtrigger was significantly lower with PFFM (p < 0.05) at 20 breaths/min (RRsim) at both pressure support (iPS) levels applied, while, at RRsim 30, DFFM had the longest ΔPtrigger compared to the other 2 total full face masks (p < 0.05). At all ventilator settings, the PTP200 was significantly shorter with DFFM than with the other two total full-face masks (p < 0.05). In terms of PTP500 ideal index (%), we did not observe significant differences between the interfaces tested. The PFFM demonstrated the best performance and synchrony at low respiratory rates, but when the respiratory rate increased, no difference between all tested total full-face masks was reported. [ABSTRACT FROM AUTHOR]

Background: Mechanical power is a major contributor to lung injury and mortality in adults receiving mechanical ventilation. Recent advances in our understanding of mechanical power have allowed the different mechanical components to be isolated. The preterm lung shares many of the same similarities that would indicate mechanical power may be relevant in this group. To date, the role of mechanical power in neonatal lung injury is unknown. We hypothesise that mechanical power maybe useful in expanding our understanding of preterm lung disease. Specifically, that mechanical power measures may account for gaps in knowledge in how lung injury is initiated. Hypothesis-generating data set: To provide a justification for our hypothesis, data in a repository at the Murdoch Children's Research Institute, Melbourne (Australia) were re-analysed. 16 preterm lambs 124–127d gestation (term 145d) who received 90 min of standardised positive pressure ventilation from birth via a cuffed endotracheal tube were chosen as each was exposed to three distinct and clinically relevant respiratory states with unique mechanics. These were (1) the respiratory transition to air-breathing from an entirely fluid-filled lung (rapid aeration and fall in resistance); (2) commencement of tidal ventilation in an acutely surfactant-deficient state (low compliance) and (3) exogenous surfactant therapy (improved aeration and compliance). Total, tidal, resistive and elastic-dynamic mechanical power were calculated from the flow, pressure and volume signals (200 Hz) for each inflation. Results: All components of mechanical power behaved as expected for each state. Mechanical power increased during lung aeration from birth to 5 min, before again falling immediately after surfactant therapy. Before surfactant therapy tidal power contributed 70% of total mechanical power, and 53.7% after. The contribution of resistive power was greatest at birth, demonstrating the initial high respiratory system resistance at birth. Conclusions: In our hypothesis-generating dataset, changes in mechanical power were evident during clinically important states for the preterm lung, specifically transition to air-breathing, changes in aeration and surfactant administration. Future preclinical studies using ventilation strategies designed to highlight different types of lung injury, including volu-, baro- and ergotrauma, are needed to test our hypothesis. [ABSTRACT FROM AUTHOR]

Objectives: To explore an optimal model to predict the response of patients with axillary lymph node (ALN) positive breast cancer to neoadjuvant chemotherapy (NAC) with machine learning using clinical and ultrasound-based radiomic features. Methods: In this study, 1014 patients with ALN-positive breast cancer confirmed by histological examination and received preoperative NAC in the Affiliated Hospital of Qingdao University (QUH) and Qingdao Municipal Hospital (QMH) were included. Finally, 444 participants from QUH were divided into the training cohort (n = 310) and validation cohort (n = 134) based on the date of ultrasound examination. 81 participants from QMH were used to evaluate the external generalizability of our prediction models. A total of 1032 radiomic features of each ALN ultrasound image were extracted and used to establish the prediction models. The clinical model, radiomics model, and radiomics nomogram with clinical factors (RNWCF) were built. The performance of the models was assessed with respect to discrimination and clinical usefulness. Results: Although the radiomics model did not show better predictive efficacy than the clinical model, the RNWCF showed favorable predictive efficacy in the training cohort (AUC, 0.855; 95% CI 0.817–0.893), the validation cohort (AUC, 0.882; 95% CI 0.834–0.928), and the external test cohort (AUC, 0.858; 95% CI 0.782–0.921) compared with the clinical factor model and radiomics model. Conclusions: The RNWCF, a noninvasive, preoperative prediction tool that incorporates a combination of clinical and radiomics features, showed favorable predictive efficacy for the response of node-positive breast cancer to NAC. Therefore, the RNWCF could serve as a potential noninvasive approach to assist personalized treatment strategies, guide ALN management, avoiding unnecessary ALND. [ABSTRACT FROM AUTHOR]

Diabetic peripheral neuropathy (DN) is a serious complication of diabetes mellitus (DM) that can lead to foot ulceration and eventual amputation if not treated properly. Therefore, detecting DN early is important. This study presents an approach for diagnosing various stages of the progression of DM in lower extremities using machine learning to classify individuals with prediabetes (PD; n = 19), diabetes without (D; n = 62), and diabetes with peripheral neuropathy (DN; n = 29) based on dynamic pressure distribution collected using pressure-measuring insoles. Dynamic plantar pressure measurements were recorded bilaterally (60 Hz) for several steps during the support phase of walking while participants walked at self-selected speeds over a straight path. Pressure data were grouped and divided into three plantar regions: rearfoot, midfoot, and forefoot. For each region, peak plantar pressure, peak pressure gradient, and pressure–time integral were calculated. A variety of supervised machine learning algorithms were used to assess the performance of models trained using different combinations of pressure and non-pressure features to predict diagnoses. The effects of choosing various subsets of these features on the model's accuracy were also considered. The best performing models produced accuracies between 94–100%, showing the proposed approach can be used to augment current diagnostic methods. [ABSTRACT FROM AUTHOR]

Objective: To compare the clinical effect and safety of nasal intermittent positive pressure ventilation (NIPPV) and noninvasive high frequency oscillatory ventilation (nHFOV) combined with minimally invasive pulmonary surfactant (PS) in the treatment of neonatal respiratory distress syndrome (NRDS). Methods: 100 children with NRDS admitted to the Department of Neonatology of our hospital from January 2019 to December 2021 were selected as the study subjects. They were randomly divided into the matched group and the observation group with 50 cases each. The newborns in the matched group were treated with NIPPV combined with minimally invasive PS, and the newborns in the observation group were treated with nHFOV combined with minimally invasive PS. The treatment-related indexes (mechanical ventilation time, oxygen exposure time, hospitalization days), improvement time of clinical symptoms (inspiratory triple concave sign, progressive dyspnea, and shortness of breath), blood gas indexes [PaO2, PaCO2, OI] The incidence of apnea, ventilation failure and complications. Results: The mechanical ventilation time, oxygen exposure time, hospitalization time of the children in the observation group were shorter than those in the matched group (P＜0.05). The improvement time of progressive dyspnea, inspiratory triple concave sign and shortness of breath in the observation group was shorter than that in the matched group (P＜0.05). The PaO2 of the children in the observation group was higher than that in the matched group at 72 hours of treatment, and the PaCO2 and OI were lower than that in the matched group (P＜0.05) The incidence of apnea and the failure rate of ventilation in the observation group were 16.00% and 10.00%, and there was no difference between the observation group and the matched group (P＞0.05). The total incidence of postoperative complications in the observation group was 4.00%, which was lower than that in the matched group (26.00%) (P＜0.05). Conclusion: Compared with NIPPV combined with non-invasive PS, nhfov combined with minimally invasive PS can more effectively improve blood gas, shorten mechanical ventilation time and reduce complications in children with NRDS. [ABSTRACT FROM AUTHOR]