Search

Background: Whether the observed lower total testosterone (tT) levels in male patients with COVID‐19 are caused by a direct impact of SARS‐CoV‐2 infection or are collateral phenomena shared by other systemic inflammatory conditions has not yet been clarified. Objectives: To investigate the independent role of COVID‐19 in reducing circulating tT levels in men. Materials and methods: We compared demographic, clinical, and hormonal values of patients with laboratory confirmed COVID‐19 admitted during the first wave of the pandemic with a cohort of consecutive male patients admitted to the intensive care unit (ICU) of the same academic center because of severe acute respiratory distress syndrome (ARDS) but without SARS‐CoV‐2 infection and no previous history of COVID‐19. Linear regression model tested the independent impact of COVID‐19 on circulating tT levels. Logistic regression model was used to test predictors of death in the entire cohort. Results: Of 286 patients with COVID‐19, 70 men had been admitted to the ICU (= cases) and were compared to 79 patients equally admitted to ICU because of severe ARDS but negative for SARS‐CoV‐2 infection and without previous history of COVID‐19 (= controls). Controls were further grouped into noninfective (n = 49) and infective‐ARDS (n = 30) patients. At baseline, controls were older (p = 0.01) and had more comorbidities (p < 0.0001). Overall, cases admitted to ICU had significantly lower circulating tT levels compared to controls (0.9 nmol/L vs. 2.1 nmol/L; vs. 1.2 nmol/L; p = 0.03). At linear regression, being negative for COVID‐19 was associated with higher tT levels (Coeff: 2.13; 95% confidence interval ‐ CI 0.71‐3.56; p = 0.004) after adjusting for age, BMI, comorbidities and IL‐6 levels. Only age and IL‐6 levels emerged to be associated with higher risk of death regardless of COVID‐19 status. Conclusions: This case‐control ex post facto study showed lower tT levels in men with COVID‐19 compared to those without COVID‐19 despite both groups have been equally admitted to ICU for severe ARDS, thus suggesting a possible direct impact of SARS‐CoV‐2 infection toward circulating tT levels and a consequent more severe clinical outcome. [ABSTRACT FROM AUTHOR]

Background: Frailty is a multi‐dimensional syndrome associated with mortality and adverse outcomes in patients admitted to the intensive care unit (ICU). Further investigation is warranted to explore the interplay among factors such as frailty, clinical deterioration triggering a medical emergency team (MET) review, and outcomes following admission to the ICU. Methods: Single‐centre, retrospective observational case‐control study of adult patients (>18 years) admitted to a medical‐surgical ICU with (cases) or without (controls) a preceding MET review between 4 h and 14 days prior. Matching was performed for age, ICU admission diagnosis, Acute Physiology and Chronic Health Evaluation III (APACHE III) score and the 8‐point Clinical Frailty Scale (CFS). Cox proportional hazard regression modelling was performed to determine associations with 30‐day mortality after admission to ICU. Results: A total of 2314 matched admissions were analysed. Compared to non‐frail patients (CFS 1–4), mortality was higher in all frail patients (CFS 5–8), at 31% vs. 13%, and in frail patients admitted after MET review at 33%. After adjusting for age, APACHE, antecedent MET review and CFS in the Cox regression, mortality hazard ratio increased by 26% per CFS point and by 3% per APACHE III point, while a MET review was not an independent predictor. Limitations of medical treatment occurred in 30% of frail patients, either with or without a MET antecedent, and this was five times higher compared to non‐frail patients. Conclusion: Frail patients admitted to ICU have a high short‐term mortality. An antecedent MET event was associated with increased mortality but did not independently predict short‐term survival when adjusting for confounding factors. The intrinsic significance of frailty should be primarily considered during MET review of frail patients. This study suggests that routine frailty assessment of hospitalised patients would be helpful to set goals of care when admission to ICU could be considered. [ABSTRACT FROM AUTHOR]

Chemical analysis by analytical instrumentation has played a major role in disease diagnosis, which is a necessary step for disease treatment. While the treatment process often targets specific organs or compounds, the diagnostic step can occur through various means, including physical or chemical examination. Chemically, the genome may be evaluated to give information about potential genetic outcomes, the transcriptome to provide information about expression actively occurring, the proteome to offer insight on functions causing metabolite expression, or the metabolome to provide a picture of both past and ongoing physiological function in the body. Mass spectrometry (MS) has been elevated among other analytical instrumentation because it can be used to evaluate all four biological machineries of the body. In addition, MS provides enhanced sensitivity, selectivity, versatility, and speed for rapid turnaround time, qualities that are important for instance in clinical procedures involving the diagnosis of a pediatric patient in intensive care or a cancer patient undergoing surgery. In this review, we provide a summary of the use of MS to evaluate biomarkers for newborn screening and cancer diagnosis. As many reviews have recently appeared focusing on MS methods and instrumentation for metabolite analysis, we sought to describe the biological basis for many metabolomic and additional omics biomarkers used in newborn screening and how tandem MS methods have recently been applied, in comparison to traditional methods. Similar comparison is done for cancer screening, with emphasis on emerging MS approaches that allow biological fluids, tissues, and breath to be analyzed for the presence of diagnostic metabolites yielding insight for treatment options based on the understanding of prior and current physiological functions of the body. [ABSTRACT FROM AUTHOR]

An increased intra-abdominal pressure can result in a manifest abdominal compartment syndrome (ACS) with significant organ damage, which is a life-threatening situation associated with a high mortality. Although the etiology is manifold and critically ill patients on the intensive care unit are particularly endangered, the disease is often not diagnosed even though the measurement of bladder pressure is available as a simple and standardized method; however, particularly the early detection of an increased intra-abdominal pressure is decisive in order to prevent the occurrence of a manifest ACS with (multi)organ failure by means of conservative measures. In cases of a conservative refractory situation, decompressive laparotomy is indicated. [ABSTRACT FROM AUTHOR]

AIM: To study the occurrence and surgical management of pressure ulcer (PU) in patients admitted in ICU of tertiary care centre. OBJECTIVES: To determine the risk factors, common sites and outcome of surgical management of pressure ulcers. MATERIALS AND METHODS: Interventional study carried out at Sri Guru Ram Das University of Health Sciences, Vallah, Sri Amritsar on 74 patients who developed pressure ulcers during their stay in ICU. RESULTS: In our study, 1050 patients were admitted in the ICU's during the period of January 2023 to March 2024. During their stay, 74 patients among them developed pressure ulcers i.e incidence was 7.04%. Most of them were Grade 1 which were conservatively managed followed by Grade 2 and 3 which were surgically managed. None of the pressure ulcer progressed to grade 4. Most common causes for such event were continuous pressure at particular point, fecal and urinary incontinence, immobility and impaired sensory perception. Sacrum, ischial tuberosities, calcaneum and shoulders were the most common sites which were frequently involved. CONCLUSION: In this study it was noted that maximum number of risk factors which were responsible for the formation of pressure ulcer was preventable. Therefore, it is very important to select appropriate and applicable preventive measures (nursing care, materials, devices and staff education). Pressure ulcer adds unnecessary burden and cost to intensive care patients. This study concludes that 'Prevention is always better than cure'. [ABSTRACT FROM AUTHOR]

Invasive mechanical ventilation is a key supportive therapy for patients on intensive care. There is increasing emphasis on personalised ventilation strategies. Clinical decision support systems (CDSS) have been developed to support this. We conducted a narrative review to assess evidence that could inform device implementation. A search was conducted in MEDLINE (Ovid) and EMBASE. Twenty-nine studies met the inclusion criteria. Role allocation is well described, with interprofessional collaboration dependent on culture, nurse:patient ratio, the use of protocols, and perception of responsibility. There were no descriptions of process measures, quality metrics, or clinical workflow. Nurse-led weaning is well-described, with factors grouped by patient, nurse, and system. Physician-led weaning is heterogenous, guided by subjective and objective information, and 'gestalt'. No studies explored decision-making with CDSS. Several explored facilitators and barriers to implementation, grouped by clinician (facilitators: confidence using CDSS, retaining decision-making ownership; barriers: undermining clinician's role, ambiguity moving off protocol), intervention (facilitators: user-friendly interface, ease of workflow integration, minimal training requirement; barriers: increased documentation time), and organisation (facilitators: system-level mandate; barriers: poor communication, inconsistent training, lack of technical support). One study described factors that support CDSS implementation. There are gaps in our understanding of ventilation practice. A coordinated approach grounded in implementation science is required to support CDSS implementation. Future research should describe factors that guide clinical decision-making throughout mechanical ventilation, with and without CDSS, map clinical workflow, and devise implementation toolkits. Novel research design analogous to a learning organisation, that considers the commercial aspects of device design, is required. [ABSTRACT FROM AUTHOR]

Background: Acute kidney injury is a prevalent complication in the Intensive Care Unit (ICU) and a significant global public health concern. It affects approximately 13 million individuals and contributes to nearly two million deaths worldwide. Acute kidney injury among Intensive Care Unit patients is closely associated with higher rates of morbidity and mortality. This study aims to assess the incidence of acute kidney injury and identify predictors among adult patients admitted to the medical Intensive Care Unit. Method: A retrospective follow-up study was conducted by reviewing charts of 317 systematically selected patients admitted to the Intensive Care Unit from September 1, 2018, to August 30, 2022, in Wachemo University Nigist Ellen Mohammed Memorial Comprehensive Specialized Hospital. The extraction tool was used for the data collection, Epi-data version 4.6.0 for data entry, and STATA version 14 for data cleaning and analysis. The Kaplan-Meier, log-rank test, and life table were used to describe the data. The Cox proportional hazard regression model was used for analysis. Results: Among the total study participants, 128 (40.4%) developed Acute Kidney Injury (AKI). The incidence rate of Acute Kidney Injury was 30.1 (95% CI: 25.33, 35.8) per 1000 person-days of observation, with a median survival time of 23 days. It was found that patients with invasive mechanical ventilation (AHR = 2.64; 95% CI: 1.46–4.78), negative fluid balance (AHR = 2.00; 95% CI: 1.30–3.03), hypertension (AHR = 1.6; 95% CI: 1.05–2.38), and a vasopressor (AHR = 1.72; 95% CI: 1.10–2.63) were independent predictors of acute kidney injury. Conclusion: The incidence of Acute Kidney Injury was a major concern in the ICU of the study area. In the intensive care unit (ICU), it was found that patients with vasopressors, invasive mechanical ventilation, negative fluid balance, and chronic hypertension were independent predictors of developing AKI. It would be better if clinicians in the ICU provided targeted interventions through close monitoring and evaluation of those patients with invasive ventilation, chronic hypertension, negative fluid balance, and vasopressors. [ABSTRACT FROM AUTHOR]

Background: The aim of this experimental study was to elucidate whether different distances between central venous catheter tips can affect drug clearance during continuous renal replacement therapy (CRRT). Central venous catheters (CVCs) are widely used in intensive care patients for drug infusion. If a patient receives CRRT, a second central dialysis catheter (CDC) is required. Where to insert CVCs is directed by guidelines, but recommendations regarding how to place multiple catheters are scarce. There are indications that a drug infused in a CVC with the tip close to the tip of the CDC, could be directly aspirated into the dialysis machine, with a risk of increased clearance. However, studies on whether clearance is affected by different CVC and CDC tip positions, when the two catheters are in the same vessel, are few. Methods: In this model with 18 piglets, gentamicin (GM) and vancomycin (VM) were infused through a CVC during CRRT. The CVC tip was placed in different positions in relation to the CDC tip from caudal, i.e., proximal to the heart, to cranial, i.e., distal to the heart. Serum and dialysate concentrations were sampled after approximately 30 min of CRRT at four different positions: when the CVC tip was 2 cm caudally (+ 2), at the same level (0), and at 2 (− 2) and 4 (− 4) cm cranially of the tip of the CDC. Clearance was calculated. A mixed linear model was performed, and level of significance was set to p < 0.05. Results: Clearance of GM had median values at + 2 cm, 0 cm, − 2 cm and − 4 cm of 17.3 (5.2), 18.6 (7.4), 20.0 (16.2) and 26.2 (12.2) ml/min, respectively (p = 0.04). Clearance of VM had median values at + 2 cm, 0 cm, − 2 cm and − 4 cm of 16.2 (4.5), 14.7 (4.9), 19.0 (10.2) and 21.2 (11.4) ml/min, respectively (p = 0.02). Conclusions: The distance between CVC and CDC tips can affect drug clearance during CRRT. A cranial versus a caudal tip position of the CVC in relation to the tip of the CDC led to the highest clearance. [ABSTRACT FROM AUTHOR]

Background: Necrotizing fasciitis (NF) is a rare but potentially life-threatening soft tissue infection. The objective of this study was to assess the association between timely surgery within 6 h and hospital mortality in patients with limb NF, and to describe the trends in patients with NF, time to surgery and standardized mortality ratio (SMR) over 11 years. Methods: This was a multicenter, retrospective cohort study of all intensive care unit patients who had emergency surgery within 24 h of hospitalization for limb NF between April 1, 2008 and March 31, 2019 in Hong Kong. Timely surgery was defined as the first surgical treatment within 6 h of initial hospitalization. Appropriate antibiotics were achieved if the patient was given antibiotic(s) for all documented pathogens prior to or on day of culture results. The primary outcome was hospital mortality. Results: There were 495 patients (median age 62 years, 349 (70.5%) males) with limb NF treated by surgery within 24 h of hospitalization over the 11 years. Appropriate antibiotic(s) were used in 392 (79.2%) patients. There were 181 (36.5%) deaths. Timely surgery was not associated with hospital mortality (Relative Risk 0.89, 95% CI: 0.73 to 1.07) but admission year, advanced age, higher severity of illness, comorbidities, renal replacement therapy, vasopressor use, and type of surgery were significant predictors in the multivariable model. There was an upward trend in NF diagnosis (1.9 cases/year, 95% CI: 0.7 to 3.1; P < 0.01; R2 = 0.60) but there was no downward trend in median time to surgery (-0.2 h/year, 95% CI: -0.4 to 0.1; P = 0.16) or SMR (-0.02/year, 95% CI: -0.06 to 0.01; P = 0.22; R2 = 0.16). Conclusions: Among patients operated within 24 h, very early surgery within 6–12 h was not associated with survival. Increasing limb NF cases were reported each year but mortality remained high despite a high rate of appropriate antibiotic use and timely surgical intervention. [ABSTRACT FROM AUTHOR]

Background Methods Results Conclusions Various postoperative sedation protocols with different anaesthetics lead to profound effects on the outcomes for post‐cardiac surgery patients. However, a comprehensive analysis of optimal postoperative sedation strategies for patients in the intensive care unit (ICU) after cardiac surgery is lacking.We systematically searched for randomized controlled trials (RCTs) in databases including PubMed and Embase. The primary outcome measured the duration of mechanical ventilation (MV) in the ICU, and the secondary outcome encompassed the length of stay (LOS) in the ICU and hospital and the monitoring adverse events.The literature included 18 RCTs (1652 patients) with 13 sedation regimens. Dexmedetomidine plus ketamine and sevoflurane were associated with a significantly reduced duration of MV when compared with propofol. Our results also suggested that dexmedetomidine plus ketamine may associated with a shorter LOS in ICU, and sevoflurane associated with a shorter LOS in the hospital, respectively.The combination of dexmedetomidine and ketamine seems to be a better option for adult patients needing sedation after cardiac surgery, and the incidence of side effects is lower with dexmedetomidine. These findings have potential implications for medication management in the perioperative pharmacotherapy of cardiac surgery patients. [ABSTRACT FROM AUTHOR]

Introduction Methods Results Conclusions Use of albumin is suggested for some patients with shock, but preferences for its use may vary among intensive care unit (ICU) physicians.We conducted an international online survey of ICU physicians with 20 questions about their use of albumin and their opinion towards a randomised trial among adults with shock comparing the use versus no use of albumin.A total of 1248 respondents participated, with a mean response rate of 37%, ranging from 18% to 75% across 21 countries. Respondents mainly worked in mixed ICUs and 92% were specialists in intensive care medicine. The reported use of albumin in general shock varied as 18% reported ‘almost never’, 22% ‘rarely’, 34% ‘occasionally’, 22% ‘frequently’ and 4% ‘almost always’ using albumin. In septic shock, 19% reported ‘almost never’, 22% ‘rarely’, 29% ‘occasionally’, 22% ‘frequently’ and 7% ‘almost always’ using albumin. Physicians’ preferences were more consistent for haemorrhagic‐ and cardiogenic shock, with more than 45% reporting ‘almost never’ using albumin. While the reported use of albumin for other purposes than resuscitation was infrequent (40%–85% reported ‘almost never’ for five other indications), the most frequent other indications were low serum albumin levels and improvement of the efficacy of diuretics. Most respondents (93%) would randomise adult ICU patients with shock to a trial of albumin versus no albumin.In this international survey, the reported preferences for the use of albumin in adult ICU patients with shock varied considerably among surveyed ICU physicians. The support for a future randomised trial was high. [ABSTRACT FROM AUTHOR]

Background: Stenotrophomonas maltophilia, a multidrug-resistant gram-negative bacteria (GNB), is an emerging nosocomial pathogen. This study assessed the clinical outcomes of GNB infections in surgical intensive care unit (SICU) patients post-abdominal surgery, focusing on the differences between S. maltophilia and other GNBs, including Pseudomonas aeruginosa. Methods: A retrospective study was conducted on SICU patients at Kaohsiung Chang Gung Memorial Hospital from 2010 to 2020, who developed GNB infections following abdominal surgery. Results: Of 442 patients, 237 had S. maltophilia and 205 had non-S. maltophilia GNB infections (including 81 with P. aeruginosa). The overall mortality rate was 44.5%, and S. maltophilia infection emerged as a significant contributor to the mortality rate in patients with GNB infections. S. maltophilia patients had longer mechanical ventilation and SICU stays, with a 30-day mortality rate of 35.4%, higher than the non-S. maltophilia GNB (22.9%) and P. aeruginosa (21%) groups. In-hospital mortality was also higher in the S. maltophilia group (53.2%) compared to the non-S. maltophilia GNB (34.6%) and P. aeruginosa groups (29.6%). Risk factors for acquiring S. maltophilia included a higher Sequential Organ Failure Assessment score and prior broad-spectrum antibiotics use. Older age, polymicrobial infections, and elevated bilirubin were associated with increased 30-day mortality in S. maltophilia patients. Conclusion: S. maltophilia infections in post-abdominal surgery patients are linked to higher mortality than non-S. maltophilia GNB and P. aeruginosa infections, emphasizing the need for early diagnosis and treatment to improve outcomes. [ABSTRACT FROM AUTHOR]

Background: Invasive pneumococcal disease (IPD) is a significant health concern in children worldwide. In this study, we aimed to analyze the clinical features, antibiotic resistance, and risk variables for poor outcomes in patients with IPD in Hangzhou. Methods: A retrospective single-centre study was performed using the pediatric intensive care (PIC) database from 2010 to 2018. The clinical characteristics, laboratory data, antimicrobial resistance, and risk factors for in-hospital mortality and sepsis in patients with IPD in intensive care units (ICUs) were analyzed systematically. Results: A total of 178 IPD patients were included in the study. The majority of the IPD children were 2–10 years old. Antimicrobial resistance tests of S. pneumoniae isolates revealed high resistance to erythromycin, tetracycline and compound sulfamethoxazole (SMZ-Co). All the isolates were sensitive to vancomycin, linezolid, moxifloxacin, telithromycin, ofloxacin, and levofloxacin. IPD patients may experience poor outcomes, including death and sepsis. The in-hospital mortality was 3.93%, and 34.27% of patients suffered from sepsis. Temperature (OR 3.80, 95% CI 1.62–8.87; P = 0.0021), Partial Pressure of Oxygen in Arterial Blood (PaO2) (OR 0.99, 95% CI 0.98-1.00; P = 0.0266), and albumin (OR 0.89, 95% CI 0.80–0.99; P = 0.0329) were found to be independent risk factors for sepsis in children with IPD. Conclusion: Pediatric IPD deserves attention in China. Appropriate surveillance and antibiotic selection are crucial in managing resistant strains. Early identification of high-risk individuals with risk factors contributes to the development of appropriate treatment strategies. [ABSTRACT FROM AUTHOR]

Introduction: Severe immune‐related adverse events (irAEs) due to immune checkpoint inhibitors (ICIs) can lead to admission to the intensive care unit (ICU). In this retrospective study, we determined the incidence, treatment patterns and survival outcomes of this patient population at a comprehensive cancer center. Methods: All patients admitted to the ICU due to irAEs from ICI treatment between January 2015 and July 2022 were included. Descriptive statistics were reported on patient characteristics and treatment patterns during hospital admission. Overall survival (OS) from the time of ICU discharge to death was estimated using the Kaplan–Meier method. Results: Over the study period, 5561 patients received at least one ICI administration, of which 32 patients (0.6%) were admitted to the ICU due to irAEs. Twenty patients were treated with anti‐PD‐1 plus anti‐CTLA‐4 treatment, whereas 12 patients were treated with ICI monotherapy. The type of irAEs were de novo diabetes‐related ketoacidosis (n = 8), immune‐related gastrointestinal toxicity (n = 8), myocarditis or myositis (n = 10), nephritis (n = 3), pneumonitis (n = 2), and myelitis (n = 1). The median duration of ICU admission was 3 days (interquartile range: 2–6 days). Three patients died during ICU admission. The median OS of the patients who were discharged from the ICU was 18 months (95% confidence interval, 5.0—NA). Conclusion: The incidence of irAEs leading to ICU admission in patients treated with ICI was low in this study. ICU mortality due to irAEs was low and a subset of this patient population even had long‐term survival. [ABSTRACT FROM AUTHOR]

The length of stay in an intensive care unit is used as a benchmark for measuring resource consumption and quality of care and predicts a higher risk of readmission. The study aimed to assess the outcome and factors associated with prolonged intensive care unit stays among those admitted to adult intensive care units of selected public hospitals in Addis Ababa from January 1, 2022, to December 31, 2022. A multicenter retrospective chart review was conducted involving 409 adult patients. Binary logistic regression was used to assess factors associated with a prolonged stay and chi-square tests were used to assess associations and differences in outcomes for prolonged stays. The study, involving 409 of 421 individuals, revealed a predominantly male (55.0%) and the median age of study participants was 38, with an interquartile range (27, 55). Approximately 16.9% experienced prolonged stays, resulting in a 43.5% mortality rate. After adjustments for confounders, there were significant associations with prolonged stays for sedative/hypnotics, readmission, and complications. The study revealed that for every six patients admitted to the intensive care unit, one patient stayed longer, with nearly half experiencing mortality, demanding increased attention. The study emphasized the critical need for improvement in addressing associations between sedative/hypnotics, readmissions, complications, and prolonged stays. [ABSTRACT FROM AUTHOR]

Background: Continuous monitoring of mitral annular plane systolic excursion (MAPSE) using transesophageal echocardiography (TEE) may improve the evaluation of left ventricular (LV) function in postoperative intensive care patients. We aimed to assess the utility of continuous monitoring of LV function using TEE and artificial intelligence (autoMAPSE) in postoperative intensive care patients. Methods: In this prospective observational study, we monitored 50 postoperative intensive care patients for 120 min immediately after cardiac surgery. We recorded a set of two-chamber and four-chamber TEE images every five minutes. We defined monitoring feasibility as how often the same wall from the same patient could be reassessed, and categorized monitoring feasibility as excellent if the same LV wall could be reassessed in ≥ 90% of the total recordings. To compare autoMAPSE with manual measurements, we rapidly recorded three sets of repeated images to assess precision (least significant change), bias, and limits of agreement (LOA). To assess the ability to identify changes (trending ability), we compared changes in autoMAPSE with the changes in manual measurements in images obtained during the initiation of cardiopulmonary bypass as well as before and after surgery. Results: Monitoring feasibility was excellent in most patients (88%). Compared with manual measurements, autoMAPSE was more precise (least significant change 2.2 vs 3.1 mm, P < 0.001), had low bias (0.4 mm), and acceptable agreement (LOA − 2.7 to 3.5 mm). AutoMAPSE had excellent trending ability, as its measurements changed in the same direction as manual measurements (concordance rate 96%). Conclusion: Continuous monitoring of LV function was feasible using autoMAPSE. Compared with manual measurements, autoMAPSE had excellent trending ability, low bias, acceptable agreement, and was more precise. [ABSTRACT FROM AUTHOR]

Background: As the opioid public health crisis evolves to include fentanyl and other potent synthetic opioids, more patients are admitted to the hospital with serious complications of drug use and frequently require higher levels of care, including intensive care unit (ICU) admission, for acute and chronic conditions related to opioid use disorder (OUD). This patient population poses a unique challenge when managing sedation and ensuring adequate ventilation while intubated given their high opioid requirements. Starting a patient on medications such as buprenorphine may be difficult for inpatient providers unfamiliar with its use, which may lead to undertreatment of patients with OUD, prolonged mechanical ventilation and length of stay. Methods: We developed a 7-day buprenorphine low dose overlap initiation (LDOI) schedule for patients with OUD admitted to the ICU (Table 1). Buprenorphine tablets were split by pharmacists and placed into pre-made blister packs as a kit to be loaded into the automated medication dispensing machine for nursing to administer daily. An internal quality review validated the appropriate dosing of split-dose tablets. To simplify order entry and increase prescriber comfort with this new protocol, we generated an order set within our electronic health record software with prebuilt buprenorphine titration orders. This protocol was implemented alongside patient and healthcare team education and counseling on the LDOI process, with follow-up offered to all patients upon discharge. Results: Here we report a series of 6 ICU patients started on buprenorphine using the LDOI schedule with split buprenorphine tablets. None of the 6 patients experienced precipitated withdrawal upon buprenorphine initiation using the LDOI schedule, and 5/6 patients were successfully extubated during the buprenorphine initiation. Four of six patients had a decrease in daily morphine milligram equivalents, with 3 patients transitioning to buprenorphine alone. Conclusion: Initiating buprenorphine via LDOI was found to be successful in the development of a protocol for critically ill patients with OUD. We examined LDOI of buprenorphine in intubated ICU patients and found no events of acute precipitated withdrawal. This protocol can be used as a guide for other institutions seeking to start critically ill patients on medication treatment for OUD during ICU admission. [ABSTRACT FROM AUTHOR]

Background: Patients who receive invasive mechanical ventilation (IMV) in the intensive care unit (ICU) have exhibited lower in-hospital mortality rates than those who are treated outside. However, the patient-, hospital-, and regional factors influencing the ICU admission of patients with IMV have not been quantitatively examined. Methods: This retrospective cohort study used data from the nationwide Japanese inpatient administrative database and medical facility statistics. We included patients aged ≥ 15 years who underwent IMV between April 2018 and March 2019. The primary outcome was ICU admission on the day of IMV initiation. Multilevel logistic regression analyses incorporating patient-, hospital-, or regional-level variables were used to assess cluster effects by calculating the intraclass correlation coefficient (ICC), median odds ratio (MOR), and proportional change in variance (PCV). Results: Among 83,346 eligible patients from 546 hospitals across 140 areas, 40.4% were treated in ICUs on their IMV start day. ICU admission rates varied widely between hospitals (median 0.7%, interquartile range 0–44.5%) and regions (median 28.7%, interquartile range 0.9–46.2%). Multilevel analyses revealed significant effects of hospital cluster (ICC 82.2% and MOR 41.4) and regional cluster (ICC 67.3% and MOR 12.0). Including patient-level variables did not change these ICCs and MORs, with a PCV of 2.3% and − 1.0%, respectively. Further adjustment for hospital- and regional-level variables decreased the ICC and MOR, with a PCV of 95.2% and 85.6%, respectively. Among the hospital- and regional-level variables, hospitals with ICU beds and regions with ICU beds had a statistically significant and strong association with ICU admission. Conclusions: Our results revealed that primarily hospital and regional factors, rather than patient-related ones, opposed ICU admissions for patients with IMV. This has important implications for healthcare policymakers planning interventions for optimal ICU resource allocation. [ABSTRACT FROM AUTHOR]

Blood flow infections (BSIs) is common occurrences in intensive care units (ICUs) and are associated with poor prognosis. The study aims to identify risk factors and assess mortality among BSI patients admitted to the ICU at Shanghai Ruijin hospital north from January 2022 to June 2023. Additionally, it seeks to present the latest microbiological isolates and their antimicrobial susceptibility. Independent risk factors for BSI and mortality were determined using the multivariable logistic regression model. The study found that the latest incidence rate of BSI was 10.11%, the mortality rate was 35.21% and the mean age of patients with BSI was 74 years old. Klebsiella pneumoniae was the predominant bacterial isolate. Logistic multiple regression revealed that tracheotomy, tigecycline, gastrointestinal bleeding, shock, length of hospital stay, age and laboratory indicators (such as procalcitonine and hemoglobin) were independent risk factors for BSI. Given the elevated risk associated with use of tracheotomy and tigecycline, it underscores the importance of the importance of cautious application of tracheostomy and empirical antibiotic management strategies. Meanwhile, the independent risk factors of mortality included cardiovascular disease, length of hospital stay, mean platelet volume (MPV), uric acid levels and ventilator. BSI patients exhibited a significant decrease in platelet count, and MPV emerged as an independent factor of mortality among them. Therefore, continuous monitoring of platelet-related parameters may aid in promptly identifying high-risk patients and assessing prognosis. Moreover, monitoring changes in uric acid levels may serve as an additional tool for prognostic evaluation in BSI patients. [ABSTRACT FROM AUTHOR]

Aim: Determine the optimal antibiotic choice for lower respiratory tract infection (LRTI) in children with neurodisability. Methods: Embase, Ovid Emcare and MEDLINE were searched for studies from inception to January 2023. All studies, except case reports, focusing on the antibiotic treatment of LRTI in children, with neurodisabilities were included. Outcomes included length of stay, intensive care admission and mortality. Results: Nine studies met the inclusion criteria (5115 patients). All the studies were of low quality. The shortest length of stay was with anaerobic and gram-positive cover. Five studies used anaerobic, gram-positive and gram-negative cover (e.g., amoxicillinclavulanic acid), which was frequently adequate. In one large study, it was better than gram-positive and gram-negative cover alone (e.g. ceftriaxone). Those unresponsive or more unwell at presentation improved faster on Pseudomonas aeruginosa cover (e.g., piperacillin-tazobactam). Conclusion: In this context, anaerobic, gram-positive and gram-negative cover is just as effective as P. aeruginosa cover, supporting empiric treatment with amoxicillin-clavulanic acid. If there is a failure to improve, broadening to include P. aeruginosa could be considered. This is consistent with a consensus statement on the treatment of LRTI in children with neurodisability. An accepted definition for what constitutes LRTI in this cohort is required before designing prospective randomised trials. [ABSTRACT FROM AUTHOR]

Until the availability of an effective and practical vaccine, there is a serious need to recognize alternative treatments for coronavirus disease 2019 (COVID-19). This study aimed to determine whether major ozonated autohemotherapy (MOAH) can improve the clinical and paraclinical parameters in critically-ill patients with COVID-19 requiring mechanical ventilation. In this controlled trial, we enrolled 40 critically ill COVID-19 patients receiving invasive mechanical ventilation. The enrolled patients were then randomized into the MOAH and control groups. The patients in the MOAH group received MOAH three times per week (10 times in total) in addition to routine treatment and standard critical supportive care. Patients in the control group were only given regular treatment and standard critical supportive care. The patients in the MOAH group had more days of breathing with no aid than those in the control group. Moreover, the length of stay in the intensive-care unit was significantly lower in the MOAH group than in the control group. MOAH resulted in higher ventilation-free days and less intensive-care unit stay compared with the control treatment. In COVID-19 patients undergoing mechanical ventilation, MOAH with routine treatment resulted in more ventilator-free days and less intensive-care unit stay compared with the standard therapy. [ABSTRACT FROM AUTHOR]

Aim: Knowledge of risk factors may provide strategies to reduce the high burden of delirium in intensive care unit (ICU) patients. We aimed to compare the risk of delirium after deep sedation with propofol versus midazolam in ICU patients. Methods: In this prospective cohort study, ICU patients who were in an unarousable state for ≥24 h due to continuous sedation with propofol and/or midazolam were included. Patients admitted ≤24 h, those with an acute neurological disorder and those receiving palliative sedation were excluded. ICU patients were assessed daily for delirium during the 7 days following an unarousable state due to continuous sedation. Results: Among 950 included patients, 605 (64%) subjects were delirious during the 7 days after awaking. The proportion of subsequent delirium was higher after midazolam sedation (152/207 [73%] patients) and after both propofol and midazolam sedation (257/377 [68%] patients), compared to propofol sedation only (196/366 [54%] patients). Midazolam sedation (adjusted cause‐specific hazard ratio [adj. cause‐specific HR] 1.32, 95% confidence interval [CI] 1.05‐1.66) and propofol and midazolam sedation (adj. cause‐specific HR 1.29, 95% CI 1.06‐1.56) were associated with a higher risk of subsequent delirium compared to propofol sedation only. Conclusion: This study among sedated ICU patients suggests that, compared to propofol sedation, midazolam sedation is associated with a higher risk of subsequent delirium. This risk seems more apparent in patients with high cumulative midazolam intravenous doses. Our findings underpin the recommendations of the Society of Critical Care Medicine Pain, Agitation/sedation, Delirium, Immobility (rehabilitation/mobilization), and Sleep (disruption) guidelines to use propofol over benzodiazepines for sedation in ICU patients. [ABSTRACT FROM AUTHOR]

The diagnosis of invasive Candida infection remains challenging because of tests with slow turnaround times or mediocre performance. T2magnetic resonance imaging is a new diagnostic tool. We investigated the diagnostic accuracy of the T2Candida panel (T2) in comparison with blood culture (BC) and the SeptiFast (SF) for the detection of five different Candida species among high-risk intensive care unit patients with suspected candidemia. We analysed blood samples collected from patients with suspected candidemia (177 samples from 138 patients) from August 2018 to April 2020. Blood samples were collected and analysed concurrently by BC, SF, and T2Candida. Subsequently, based on clinical and microbiological findings, patient samples were assigned to specific risk categories (proven, probable, and no candidemia). Twenty-two samples from 17 patients were classified as proven candidemia, and 15 samples from 14 patients were classified as probable candidemia. A sensitivity of 68.2% (95% CI, 45–86%) was observed for the BC and the SF, and a sensitivity of 63.6% (95% CI, 41–83%) was observed for the T2 when only cases with proven candidemia were evaluated. For proven and probable candidemia, the sensitivity was 40.5% (95% CI, 23–58%) for BC, 81.1% (95% CI, 65–92%) for SF, and 73.0% (95% CI, 56–86%) for T2. The diagnostic performance of SF and T2 was similar. For samples with proven/probable candidemia, SF and T2 had a higher sensitivity compared to BC. Used in conjunction with other diagnostic methods, T2 can replace the no longer available SF for the diagnosis of candidemia, enabling the timely initiation of targeted antifungal therapy. [ABSTRACT FROM AUTHOR]

The kidney injury molecule (KIM)-1 is shed from proximal tubular cells in acute kidney injury (AKI), relaying tubular epithelial proliferation. Additionally, KIM-1 portends complex immunoregulation and is elevated after exposure to lipopolysaccharides. It thus may represent a biomarker in critical illness, sepsis, and sepsis-associated AKI (SA-AKI). To characterise and compare KIM-1 in these settings, we analysed KIM-1 serum concentrations in 192 critically ill patients admitted to the intensive care unit. Irrespective of kidney dysfunction, KIM-1 serum levels were significantly higher in patients with sepsis compared with other critical illnesses (191.6 vs. 132.2 pg/mL, p = 0.019) and were highest in patients with urogenital sepsis, followed by liver failure. Furthermore, KIM-1 levels were significantly elevated in critically ill patients who developed AKI within 48 h (273.3 vs. 125.8 pg/mL, p = 0.026) or later received renal replacement therapy (RRT) (299.7 vs. 146.3 pg/mL, p < 0.001). KIM-1 correlated with markers of renal function, inflammatory parameters, hematopoietic function, and cholangiocellular injury. Among subcomponents of the SOFA score, KIM-1 was elevated in patients with hyperbilirubinaemia (>2 mg/dL, p < 0.001) and thrombocytopenia (<150/nL, p = 0.018). In univariate and multivariate regression analyses, KIM-1 predicted sepsis, the need for RRT, and multi-organ dysfunction (MOD, SOFA > 12 and APACHE II ≥ 20) on the day of admission, adjusting for relevant comorbidities, bilirubin, and platelet count. Additionally, KIM-1 in multivariate regression was able to predict sepsis in patients without prior (CKD) or present (AKI) kidney injury. Our study suggests that next to its established role as a biomarker in kidney dysfunction, KIM-1 is associated with sepsis, biliary injury, and critical illness severity. It thus may offer aid for risk stratification in these patients. [ABSTRACT FROM AUTHOR]

Aim: To describe different patterns of communication aimed at preventing, identifying and managing symptoms between mechanically ventilated patients and clinicians in the intensive care unit. Design: We conducted a fieldwork study with triangulation of participant observation and individual interviews. Methods: Participant observation of nine patients and 50 clinicians: nurses, physiotherapists and physicians. Subsequent individual face‐to‐face interviews with nine of the clinicians, and six of the patients after they had regained their ability to speak and breathe spontaneously, were fully alert and felt well enough to sit through the interview. Findings: Symptom communication was found to be an integral part of patient care. We identified three communication patterns: (1) proactive symptom communication, (2) reactive symptom communication and (3) lack of symptom communication. The three patterns co‐existed in the cases and the first two complemented each other. The third pattern represents inadequate management of symptom distress. Conclusion: Recognition of symptoms in non‐speaking intensive care patients is an important skill for clinicians. Our study uncovered three patterns of symptom communication, two of which promoted symptom management. The third pattern suggested that clinicians did not always acknowledge the symptom distress. Implications for Patient Care: Proactive and reactive symptom assessment of non‐speaking patients require patient verification when possible. Improved symptom prevention, identification and management require a combination of sound clinical judgement and attentiveness towards symptoms, implementation and use of relevant assessment tools, and implementation and skill building in augmentative and alternative communication. Impact: This study addressed the challenges of symptom communication between mechanically ventilated patients and clinicians in the intensive care unit. Our findings may have an impact on patients and clinicians concerned with symptom management in intensive care units. Reporting Method: We used the consolidated criteria for reporting qualitative research. Patient Contribution: A user representative was involved in the design of the study. [ABSTRACT FROM AUTHOR]

Summary: The planned withdrawal of life‐sustaining treatment is a common practice in the intensive care unit for patients where ongoing organ support is recognised to be futile. Predicting the time to asystole following withdrawal of life‐sustaining treatment is crucial for setting expectations, resource utilisation and identifying patients suitable for organ donation after circulatory death. This systematic review evaluates the literature for variables associated with, and predictive models for, time to asystole in patients managed on intensive care units. We conducted a comprehensive structured search of the MEDLINE and Embase databases. Studies evaluating patients managed on adult intensive care units undergoing withdrawal of life‐sustaining treatment with recorded time to asystole were included. Data extraction and PROBAST quality assessment were performed and a narrative summary of the literature was provided. Twenty‐three studies (7387 patients) met the inclusion criteria. Variables associated with imminent asystole (<60 min) included: deteriorating oxygenation; absence of corneal reflexes; absence of a cough reflex; blood pressure; use of vasopressors; and use of comfort medications. We identified a total of 20 unique predictive models using a wide range of variables and techniques. Many of these models also underwent secondary validation in further studies or were adapted to develop new models. This review identifies variables associated with time to asystole following withdrawal of life‐sustaining treatment and summarises existing predictive models. Although several predictive models have been developed, their generalisability and performance varied. Further research and validation are needed to improve the accuracy and widespread adoption of predictive models for patients managed in intensive care units who may be eligible to donate organs following their diagnosis of death by circulatory criteria. [ABSTRACT FROM AUTHOR]

Study Design. A retrospective case-series. Objective. The study aims to use machine learning to predict the discharge destination of spinal cord injury (SCI) patients in the intensive care unit. Summary of Background Data. Prognostication following SCI is vital, especially for critical patients who need intensive care. Patients and Methods. Clinical data of patients diagnosed with SCI were extracted from a publicly available intensive care unit database. The first recorded data of the included patients were used to develop a total of 98 machine learning classifiers, seeking to predict discharge destination (eg, death, further medical care, home, etc.). The microaverage area under the curve (AUC) was the main indicator to assess discrimination. The best average-AUC classifier and the best death-sensitivity classifier were integrated into an ensemble classifier. The discrimination of the ensemble classifier was compared with top death-sensitivity classifiers and top average-AUC classifiers. In addition, prediction consistency and clinical utility were also assessed. Results. A total of 1485 SCI patients were included. The ensemble classifier had a microaverage AUC of 0.851, which was only slightly inferior to the best average-AUC classifier (P=0.10). The best average-AUC classifier death sensitivity was much lower than that of the ensemble classifier. The ensemble classifier had a death sensitivity of 0.452, which was inferior to the top 8 death-sensitivity classifiers, whose microaverage AUC were inferior to the ensemble classifier (P<0.05). In addition, the ensemble classifier demonstrated a comparable Brier score and superior net benefit in the DCA when compared with the performance of the origin classifiers. Conclusions. The ensemble classifier shows an overall superior performance in predicting discharge destination, considering discrimination ability, prediction consistency, and clinical utility. This classifier system may aid in the clinical management of critical SCI patients in the early phase following injury. [ABSTRACT FROM AUTHOR]

Evaluation of left ventricular (LV) function in critical care patients is useful for guidance of therapy and early detection of LV dysfunction, but the tools currently available are too time-consuming. To resolve this issue, we previously proposed a method for the continuous and automatic quantification of global LV function in critical care patients based on the detection and tracking of anatomical landmarks on transesophageal heart ultrasound. In the present study, our aim was to improve the performance of mitral annulus detection in transesophageal echocardiography (TEE). We investigated several state-of-the-art networks for both the detection and tracking of the mitral annulus in TEE. We integrated the networks into a pipeline for automatic assessment of LV function through estimation of the mitral annular plane systolic excursion (MAPSE), called autoMAPSE. TEE recordings from a total of 245 patients were collected from St. Olav's University Hospital and used to train and test the respective networks. We evaluated the agreement between autoMAPSE estimates and manual references annotated by expert echocardiographers in 30 Echolab patients and 50 critical care patients. Furthermore, we proposed a prototype of autoMAPSE for clinical integration and tested it in critical care patients in the intensive care unit. Compared with manual references, we achieved a mean difference of 0.8 (95% limits of agreement: –2.9 to 4.7) mm in Echolab patients, with a feasibility of 85.7%. In critical care patients, we reached a mean difference of 0.6 (95% limits of agreement: –2.3 to 3.5) mm and a feasibility of 88.1%. The clinical prototype of autoMAPSE achieved real-time performance. Automatic quantification of LV function had high feasibility in clinical settings. The agreement with manual references was comparable to inter-observer variability of clinical experts. [ABSTRACT FROM AUTHOR]

Traumatic brain injury (TBI) is a leading global cause of morbidity and mortality. Intracranial hypertension following moderate-to-severe TBI (m-sTBI) is a potentially modifiable secondary cerebral insult and one of the central therapeutic targets of contemporary neurocritical care. External ventricular drain (EVD) insertion is a common therapeutic intervention used to control intracranial hypertension and attenuate secondary brain injury. However, the optimal timing of EVD insertion in the setting of m-sTBI is uncertain and practice variation is widespread. Therefore, we aimed to assess if there is an association between timing of EVD placement and functional neurological outcome at 6 months post m-sTBI. We pooled individual patient data for all relevant harmonizable variables from the Erythropoietin in Traumatic Brain Injury (EPO-TBI) and Prophylactic Hypothermia Trial to Lessen Traumatic Brain Injury (POLAR) randomized control trials, and the Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) Core Study version 3.0 and Australia-Europe NeuroTrauma Effectiveness Research in TBI (Oz-ENTER) prospective observational studies to create a combined dataset. The Glasgow Coma Scale (GCS) score was used to define TBI severity and we included all patients admitted to an intensive care unit with a GCS ≤12, who were 15 years or older and underwent EVD placement within 7 days of injury. We used hierarchical multi-variable logistic regression models to study the association between EVD insertion within 24 h of injury (early) compared with EVD insertion more than 24 h after injury (late) and 6-month functional neurological outcome measured using the Glasgow Outcome Score Extended (GOSE). In total, 2536 patients were assessed. Of these, 502 (20%) underwent early EVD insertion and 145 (6%) underwent late EVD insertion. Following adjustment for the IMPACT (International Mission for Prognosis and Analysis of Clinical Trials in TBI) score extended (Core + CT), sex, injury severity score, study and treatment site, patients receiving a late EVD had higher odds of death or severe disability (GOSE 1-4) at 6 months follow-up than those receiving an early EVD adjusted odds ratio; 95% confidence interval, 2.14; 1.22-3.76; p = 0.008. Our study suggests that in patients with m-sTBI where an EVD is needed, early (≤ 24 h post-injury) insertion may result in better long-term functional outcomes. This finding supports future prospective investigation in this area. [ABSTRACT FROM AUTHOR]

Joint models linking longitudinal biomarkers or recurrent event processes with a terminal event, for example, mortality, have been studied extensively. Motivated by studies of recurrent delirium events in patients receiving care in an intensive care unit (ICU), we devise a joint model for a recurrent event process and multiple terminal events. Being discharged alive from the ICU or experiencing mortality may be associated with a patient's hazard of delirium, violating the assumption of independent censoring. Moreover, the direction of the association between the hazards of delirium and mortality may be opposite of the direction of association between the hazards of delirium and ICU discharge. Hence treating either terminal event as independent censoring may bias inferences. We propose a competing joint model that uses a latent frailty to link a patient's recurrent and competing terminal event processes. We fit our model to data from a completed placebo‐controlled clinical trial, which studied whether Haloperidol could prevent death and delirium among ICU patients. The clinical trial served as a foundation for a simulation study, in which we evaluate the properties, for example, bias and confidence interval coverage, of the competing joint model. As part of the simulation study, we demonstrate the shortcomings of using a joint model with a recurrent delirium process and a single terminal event to study delirium in the ICU. Lastly, we discuss limitations and possible extensions for the competing joint model. The competing joint model has been added to frailtypack, an R package for fitting an assortment of joint models. [ABSTRACT FROM AUTHOR]

Background: This study aimed to create a method for promptly predicting acute kidney injury (AKI) in intensive care patients by applying interpretable, explainable artificial intelligence techniques. Methods: Population data regarding intensive care patients were derived from the Medical Information Mart for Intensive Care IV database from 2008 to 2019. Machine learning (ML) techniques with six methods were created to construct the predicted models for AKI. The performance of each ML model was evaluated by comparing the areas under the curve (AUC). Local Interpretable Model-Agnostic Explanations (LIME) method and Shapley Additive exPlanation values were used to decipher the best model. Results: According to inclusion and exclusion criteria, 53,150 severely sick individuals were included in the present study, of which 42,520 (80%) were assigned to the training group, and 10,630 (20%) were allocated to the validation group. Compared to the other five ML models, the eXtreme Gradient Boosting (XGBoost) model greatly predicted AKI following ICU admission, with an AUC of 0.816. The top four contributing variables of the XGBoost model were SOFA score, weight, mechanical ventilation, and the Simplified Acute Physiology Score II. An AKI and Non-AKI cases were predicted separately using the LIME algorithm. Conclusion: Overall, the constructed clinical feature-based ML models are excellent in predicting AKI in intensive care patients. It would be constructive for physicians to provide early support and timely intervention measures to intensive care patients at risk of AKI. [ABSTRACT FROM AUTHOR]

Background: This review aims to study the clinical characteristics, diagnostic results, treatments, and outcomes in patients with heterotopic ossification following COVID-19 infection. Methods: A literature search for eligible articles was conducted using MEDLINE/Pubmed, Global Health, and Scopus databases (January 12th, 2023), including all case reports and case series from any country and language. The criteria for inclusion in this review were cases of COVID-19 infection subsequently developing heterotopic ossification. Results: This systematic review analysed 15 reports (n = 20 patients) documenting cases of heterotopic ossification following COVID-19 infection. 80% of the patients were male, with a median age of 59 years. All patients required intensive care unit stay with an average duration of 48.5 days. Mechanical ventilation was necessary for all patients and 30% of them underwent tracheostomy. Common symptoms included stiffness and pain, most frequently affecting multiple locations (70%), with the hips and shoulders being predominantly involved. X-rays were the most commonly used imaging modality, followed by computed tomography. Although treatment was given, some of the patients continued to experience symptoms, particularly stiffness. Conclusion: 20 patients who developed heterotopic ossification after COVID-19 have been reported, the majority of which had at least two independent risk factors for this condition. The link between those two clinical entities is therefore uncertain, requiring further investigation. It is nonetheless important to suspect heterotopic ossification in patients with severe COVID-19 infection, prolonged immobilisation, mechanical ventilation, who develop joint pain and stiffness, as this condition can significantly impact patients' quality of life. Protocol registration: CRD42023393516. [ABSTRACT FROM AUTHOR]

Introduction: Early mobilization is key in neurologically impaired persons, limiting complications and improving long-term recovery. Self-balanced exoskeletons are used in rehabilitation departments to help patients stand and walk. We report the first case series of exoskeleton use in acute neurosurgery and intensive care patients, evaluating safety, clinical feasibility and patients' satisfaction. Methods: We report a retrospective observational study including individuals hospitalized in the neurosurgical intensive care and neurosurgery departments. We included patients with a medical prescription for an exoskeleton session, and who met no contraindication. Patients benefited from standing sessions using a self-balanced exoskeleton (Atalante, Wandercraft, France). Patients and sessions data were collected. Safety, feasibility and adherence were evaluated. Results: Seventeen patients were scheduled for 70 standing sessions, of which 27 (39%) were completed. They were typically hospitalized for intracranial hemorrhage (74%) and presented with unilateral motor impairments, able to stand but with very insufficient weight shifting to the hemiplegic limb, requiring support (MRC 36.2 ± 3.70, SPB 2.0 ± 1.3, SPD 0.7 ± 0.5). The average duration of standing sessions was 16 ± 9 min. The only side effect was orthostatic hypotension (18.5%), which resolved with returning to seating position. The most frequent reason for not completing a session was understaffing (75%). All patients were satisfied and expressed a desire to repeat it. Conclusions: Physiotherapy using the exoskeleton is safe and feasible in the acute neurosurgery setting, although it requires adaptation from the staff to organize the sessions. An efficacy study is ongoing to evaluate the benefits for the patients. [ABSTRACT FROM AUTHOR]

Background: Previous studies have explored the association between the number of cases and patient outcomes for critical illnesses such as sepsis and trauma, as well as various surgeries, with the expectation that a higher number of cases would have a more favorable effect on patient outcomes. The aim of this study was to elucidate the association among intensive care unit (ICU) case volume, specialization, and patient outcomes in critically ill emergency patients and to determine how ICU case volumes and specializations impact the outcomes of these patients in Japanese ICUs. Methods: Utilizing data from the Japanese Intensive Care PAtient Database (JIPAD) from April 2015 to March 2021, this retrospective cohort study was conducted in 80 ICUs across Japan and included 72,214 emergency patients aged ≥ 16 years. The primary outcome measure was in-hospital mortality, and the secondary outcomes encompassed ICU mortality, 28-day mortality, ventilator-free days, and the lengths of ICU and hospital stays. Bayesian hierarchical generalized linear mixed models were used to adjust for patient- and ICU-level variables. Results: This study revealed a significant association between a higher ICU case volume and decreased in-hospital mortality. In particular, ICUs with a higher percentage (> 75%) of emergency patients showed more pronounced effects, with the odds ratios for in-hospital mortality in the higher case volume quartiles (Q2, Q3, and Q4) being 0.92 (95% credible interval [CI]: 0.88–0.96), 0.70 (95% CI: 0.67–0.73), and 0.78 (95% CI: 0.73–0.83), respectively, compared with the lowest quartile (Q1). Similar trends were observed for various secondary outcomes. Conclusions: Higher ICU case volumes were significantly associated with lower in-hospital mortality rates in Japanese ICUs predominantly treating critically ill emergency patients. These findings emphasize the importance of ICU specialization and highlight the potential benefits of centralized care for critically ill emergency patients. These findings are potential insights for improving health care policy in Japan and may be valuable in emergency care settings in other countries with similar healthcare systems, after careful consideration of contextual differences. [ABSTRACT FROM AUTHOR]

Background/Objectives: The hypercoagulable state associated with COVID-19 infection is associated with adverse outcomes and mortality. Studies have also demonstrated high rates of venous thromboembolism (VTE) events among patients with sepsis. We aimed to evaluate how the increase in thrombotic events in critically ill patients with COVID-19 infection compares to that of critically ill patients with non-COVID-19 sepsis. Methods: A chart review was performed of patients 18 years or older admitted to the intensive care unit (ICU) at Tampa General Hospital between 1 January 2020 and 31 December 2020 diagnosed with COVID-19 or sepsis secondary to other pathogens. Non-COVID-19 sepsis patients and COVID-19 patients were propensity-matched 3:1 on the Charlson Comorbidity Index. Multivariate analyses adjusting for confounding were conducted to report odds ratio (OR) and 95% confidence intervals (95% CIs) of predictors for thrombotic events and overall mortality. Results: After propensity score matching, 492 sepsis patients and 164 COVID-19 patients were included in the analysis. COVID-19 patients were significantly older (p = 0.021) and showed higher BMI (p < 0.001) than sepsis patients. COVID-19 patients did not show significantly higher odds of thrombosis after adjustment for confounders (OR 0.85, 95% CI 0.42–1.72), but had significantly lower odds of mortality than sepsis patients (OR 0.33, 95% CI 0.16–0.66). Conclusions: Our results suggest that further study is required to lower the rate of VTE in COVID-19 and non-COVID-19 sepsis patients admitted to the ICU; it is also reasonable to consider similar thromboembolism practices between these two patient groups. [ABSTRACT FROM AUTHOR]

Background: Persistent hypotension in the intensive care unit (ICU) is associated with increased mortality. Predicting acute hypotensive events can lead to timely intervention. We aimed to develop a prediction model of acute hypotensive events in patients admitted to the ICU. Methods: We included adult patients admitted to the Nagoya City University (NCU) Hospital ICU between January 2018 and December 2021 for model training and internal validation. The MIMIC-III database was used for external validation. A hypotensive event was defined as a mean arterial pressure < 60 mmHg for at least 5 min in 10 min. The input features were age, sex, and time-series data for vital signs. We compared the area under the receiver-operating characteristic curve (AUROC) of three machine-learning algorithms: logistic regression, the light gradient boosting machine (LightGBM), and long short-term memory (LSTM). Results: Acute hypotensive events were found in 1325/1777 (74.6%) and 2691/5266 (51.1%) of admissions in the NCU and MIMIC-III cohorts, respectively. In the internal validation, the LightGBM model had the highest AUROC (0.835), followed by the LSTM (AUROC 0.834) and logistic regression (AUROC 0.821) models. Applying only blood pressure-related features, the LSTM model achieved the highest AUROC (0.843) and consistently showed similar results in external and internal validation. Conclusions: The LSTM model using only blood pressure-related features had the highest AUROC with comparable performance in external validation. [ABSTRACT FROM AUTHOR]

Background: The role of vitamin D3 (VitD3) in modulating innate and adaptive immunity has been reported in different disease contexts. Since the start of the coronavirus disease-2019 (COVID-19) pandemic, the role of VitD3 has been highlighted in many correlational and observational studies. However, the exact mechanisms of action are not well identified. One of the mechanisms via which VitD3 modulates innate immunity is by regulating the NLRP3-inflammasome pathway, being a main underlying cause of SARS-CoV-2-induced hyperinflammation. Aims and main methods: Blood specimens of severe COVID-19 patients with or without VitD3 treatment were collected during their stay in the intensive care unit and patients were followed up for 29 days. qPCR, western blot, and ELISA were done to investigate the mechanism of action of VitD3 on the NLRP3 inflammasome activation. Key findings: We here report the ability of VitD3 to downregulate the NLRP3-inflammsome pathway in severe COVID-19 patients. Lower inflammasome pathway activation was observed with significantly lower gene and protein expression of NLRP3, cleaved caspase-1, ASC and IL-1β among severe COVID-19 patients treated with VitD3. The reduction of the inflammasome pathway was associated with a reduction in disease severity markers and enhancement of type I IFN pathway. Significance: Our data reveals an important anti-inflammatory effect of VitD3 during SARS-CoV-2 infection. Further investigations are warranted to better characterize the ability of VitD3 to control disease pathogenesis and prevent progression to severe states. This will allow for a more efficient use of a low cost and accessible treatment like VitD3. [ABSTRACT FROM AUTHOR]

Background. Cognitive symptoms and fatigue may persist after intensive care unit (ICU) care. It remains unclear whether post-COVID-19 symptoms are related to ICU care itself or the infection. Objective. The primary aim was to investigate the prevalence of residual cognitive impairment and fatigue after ICU care for COVID-19 and to evaluate the importance of demographic factors. A secondary aim was to investigate whether differences in ICU treatment between the first wave (March 2020 to July 2020) and later waves (August 2020 to January 2021) of COVID-19 were associated with differences in cognitive outcomes. Design. Prospective follow-up study. Subjects/Patients. Swedish cohort of COVID-19 patients referred from ICU. Methods. Montreal Cognitive Assessment (MoCA), Multidimensional Fatigue Inventory-20 (MFI-20), Hospital Anxiety and Depression Scale, Insomnia Severity Scale, and RAND-36 were administered approximately three months after admission to ICU. Mann–Whitney tests were used to investigate group differences, and multiple linear regression was used to investigate the relationship between fatigue and covarying factors. Results. 71 patients completed follow-up, and 60 patients underwent a cognitive screening of which 30% had MoCA scores indicative of cognitive impairment (<26 points). Higher age was related to poorer cognitive performance. Patients scored above the normal range on all subscales on the MFI-20. There was a significant difference in length of ICU stay between wave one and following waves, but no statistically significant differences emerged on cognitive screening. Intubated patients' fatigue ratings were lower compared to those not intubated—despite longer ICU stay. No difference in MoCA scores emerged between patients who were, or were not, intubated. Conclusion. Cognitive impairment and fatigue were evident in patients three months after a severe COVID-19 infection, but global cognitive functioning was not related to ICU length of stay. Less fatigue among patients who had been intubated merits further investigation. [ABSTRACT FROM AUTHOR]

Sodium valproate overdose leads to CNS depression, cerebral oedema, and severe metabolic acidosis in cases of severe toxicity. Extracorporeal removal, specifically through intermittent haemodialysis, is recommended, though not always tolerated by or accessible to haemodynamically unstable patients in intensive care units. We present a case of a male in his mid-twenties presenting following a massive, intentional overdose of 13 g of sodium valproate over 7 hours, with an initial valproate blood concentration of 975 μg/ml (normal 50-100 μg/ml). He was hypoxic and severely acidotic on arrival and was given fluids and L-carnitine according to TOXBASE guidelines. This resulted in only marginal improvement to his acidosis. Once transferred to our intensive care unit, the patient was started on inotropic support followed by continuous venovenous hemofiltration (CVVHDF) at the maximum effluent rate of 60 ml/kg/hr. Due to his persisting metabolic acidosis and worsening hyperlacataemia, dual CVVHDF was started by adding another filter in series after 26 hours, increasing the maximum effluent rate to 96 ml/kg/hr. The patient remained on dual CVVHDF for 31 hours, during which his acidosis and lactate showed considerable improvement, and he was subsequently stepped down to single-filter CVVHDF for a further 20 hours until complete resolution of his acidosis. This case report recognises dual CVVHDF as a viable salvage therapy for severe sodium valproate overdose by facilitating the achievement of a higher effluent flow rate compared to what can be accomplished with single-filter CVVHDF. [ABSTRACT FROM AUTHOR]

Background: In hemodynamically unstable patients, the passive leg raise (PLR) test is recommended for use as a self-fluid challenge for predicting preload responsiveness. However, to interpret the hemodynamic effects and reliability of the PLR, the method of performing it is of the utmost importance. Our aim was to determine the current practice of the correct application and interpretation of the PLR in intensive care patients. Methods: After ethical approval, we designed a cross-sectional online survey with a short user-friendly online questionnaire. Using a random sample of 1903 hospitals in Germany, 182 hospitals with different levels of care were invited via an email containing a link to the questionnaire. The online survey was conducted between December 2021 and January 2022. All critical care physicians from different medical disciplines were surveyed. We evaluated the correct points of concern for the PLR, including indication, contraindication, choice of initial position, how to interpret and apply the changes in cardiac output, and the limitations of the PLR. Results: A total of 292 respondents participated in the online survey, and 283/292 (97%) of the respondents completed the full survey. In addition, 132/283 (47%) were consultants and 119/283 (42%) worked at a university medical center. The question about the performance of the PLR was answered correctly by 72/283 (25%) of the participants. The limitations of the PLR, such as intra-abdominal hypertension, were correctly selected by 150/283 (53%) of the participants. The correct effect size (increase in stroke volume ≥ 10%) was correctly identified by 217/283 (77%) of the participants. Conclusions: Our results suggest a considerable disparity between the contemporary practice of the correct application and interpretation of the PLR and the practice recommendations from recently published data at German ICUs. [ABSTRACT FROM AUTHOR]

Ciprofol (HSK3486) is a newly developed, highly selective γ‐aminobutyric acid‐A (GABAA) receptor potentiator that is recently approved for a new indication of sedation for patients in the intensive care unit (ICU) in China. This analysis aimed to characterize the population pharmacokinetics (PopPKs) of ciprofol and evaluate the relationship of exposure with hypotension in mechanically ventilated patients in the ICU. A total of 462 subjects with 3918 concentration measurements from two clinical trials of mechanically ventilated patients in the ICU, four clinical trials of elective surgical patients, and six clinical trials of healthy subjects were used in the PopPK analysis. Exposure–safety relationship for hypotension was evaluated based on the data gathered from 112 subjects in two clinical trials of mechanically ventilated patients in the ICU. Ciprofol pharmacokinetics (PKs) was adequately described by a three‐compartment linear disposition model with first‐order elimination. Body weight, age, sex, blood sampling site (vein vs. arterial), study design (long‐term infusion vs. short‐term infusion), and patient population (ICU vs. non‐ICU) were identified as statistically significant covariates on the PKs of ciprofol. Within the exposure range of the mechanically ventilated ICU patient population, no meaningful association was observed between ciprofol exposure and the incidence of hypotension. These results support the dosing regimen currently used in mechanically ventilated patients in the ICU. [ABSTRACT FROM AUTHOR]

Background: It is unknown whether physicians treating critically ill patients have realistic perceptions of their patients' prognoses. Methods: We sent a survey by email to Finnish anesthesiologists to investigate their ability to estimate the probability of 1‐year survival of intensive care unit (ICU) patients based on data available at the beginning of intensive care. We presented 12 fictional but real‐life‐based patient cases and asked the respondent to estimate the probability of 1‐year survival in each case by choosing one of the alternatives 5%, 10%–90% in 10% intervals and 95%. We compared the physicians' estimates to registry data‐based realistic prognoses of comparable patients treated in the ICU. Based on the difference between the estimate and the realistic prognosis, we categorized the estimates into three groups: (1) difference less than 10 percentage points, (2) difference between 10 and 20 percentage points, and (3) difference over 20 percentage points. Results: We received 210 responses (totally 2520 estimates). Of the respondents, 43 (20.5%) were specialists working mainly in the ICU, 81 (38.6%) were specialists working occasionally in the ICU, 47 (22.4%) were specialists not working in the ICU, and 39 (18.6%) were doctors in training. The difference between the estimate and the realistic prognosis was less than 10 percentage points for 1083 (43.0%) estimates, between 10 and 20 percentage points for 645 (25.6%) estimates, and over 20 percentage points for 792 (31.4%) estimates, out of which 612 (24.3% of all estimates) underestimated and 180 (7.1%) overestimated the likelihood of survival. The median error (the median of the differences between the estimate and the realistic prognosis) for all estimates was −8.8 [interquartile range (IQR), −20.0 to −0.2], which means that the most typical response underestimated the likelihood of survival by 9 percentage points. Based on the 12 estimates, we calculated the median error for each respondent. The median (IQR) of these median errors was −8.6 (−12.6 to −5.0) for specialists working mainly in the ICU, −8.1 (−13.0 to −5.2) for specialists working occasionally in the ICU, −9.7 (−17.7 to −6.3) for specialists not working in the ICU, and −9.1 (−14.5 to −5.1) for doctors in training (p =.29). Conclusion: Finnish anesthesiologists commonly misestimate the long‐term prognoses of ICU patients, more often underestimating than overestimating the likelihood of 1‐year survival. More education about critically ill patients' prognoses and better prediction tools are needed. [ABSTRACT FROM AUTHOR]

Background: Sepsis is one of the major causes of mortality and morbidity in hospitals. Bloodstream infections (BSI) affect approximately 2% of all hospitalized patients and 70% of patients admitted to the Intensive Care Units. Detection of BSI is one of the most important tasks performed in the microbiology laboratory. Aims and Objectives: This study aims to evaluate direct antimicrobial susceptibility tests (DAST) from positive blood culture broth in suspected bacteremia and compare the DAST and conventional antimicrobial susceptibility testing (CAST) of the isolates. Materials and Methods: A descriptive study involving a total of 112 aerobic blood culture bottles flagged positively by the automated Identification System (Bac T/Alert3D) was processed. The bacteria were pelleted by two-step centrifugation of the broth from the bottle and used to make a smear for Gram stain as well as an inoculum for antimicrobial sensitivity testing by Kirby-Bauer disk diffusion method. Results: Out of 842 blood culture samples, 112 flagged positive cultures were subjected to direct gram film, 28 were found to be polymicrobial, 24 Gram-positive cocci, and 60 were Gram-negative bacilli. There was a complete match between the direct Gram stain result from the positive bottle and the Gram stain from subcultures from the bottles obtained after overnight culture on solid media. Conclusion: This study has demonstrated good concordance between the DAST and CAST results. Hence, direct AST can be implemented in a routine diagnostic laboratory. Direct AST will be helpful to decrease the turnaround time and to start early antimicrobial therapy in critically ill patients. [ABSTRACT FROM AUTHOR]

Background: The occurrence of delirium in patients who undergo elective surgeries is a common occurrence. Multiple studies have assessed the effect of different drugs in various elective procedures to decrease the prevalence of postoperative delirium. The effect of melatonin to decrease the prevalence of delirium and duration of neurosurgical intensive care unit (NSICU) stay in patients undergoing neurosurgery has not been studied previously. The current study aimed to assess the same. Aims and Objectives: To assess the effect of preoperative and postoperative melatonin administration on the prevalence of delirium in patients undergoing elective ventilation in NSICU and to assess the effect of preoperative and postoperative melatonin administration on the duration of stay in NSICU. Methods and Methods: In this prospective observational study, 60 patients undergoing various neurosurgical procedures and admitted to NSICU were included. The patients were divided into two groups: one group received a placebo (Group P-tablet Sugarfree containing Aspartame) and another group received a tablet of melatonin 3 mg (Group M) in the preoperative and postoperative period. The effect of melatonin on the prevalence of delirium and duration of NSICU stay in these two groups was observed. Results: A decreasing trend of delirium was noted in both groups (Group M and Group P) with no statistical significance. A decreased prevalence of delirium was observed in patients of group M (33.3%) at the end of 12 h post-extubation compared to Group P (43.3%). The mean duration of stay for the patients in NSICU in Groups M and P were 2.7 and 3.2 days, with the range (1-14 Days) in Group M and Group P (1-20 days), respectively. Conclusion: Although there was a decreased prevalence of delirium and a decrease in the mean duration of the intensive care unit stay in patients who received oral melatonin, these beneficial effects did not show any statistical significance once compared with the control group. [ABSTRACT FROM AUTHOR]

Background: Dexmedetomidine is a selective alpha-2-adrenoceptor agonist. It exerts both sedative and analgesic effects through mechanisms different from those of other sedatives. The safety and efficacy of dexmedetomidine are altered by various factors. Aims and Objectives: This study aims at identifying the various factors that will affect the sedative and hemodynamic responses of dexmedetomidine in seriously ill patients. Materials and Methods: A continuous infusion of dexmedetomidine (0.2-0.7 µg/kg/h) was administered to intensive care unit patients who needed sedation. We investigated the safety and effectiveness of administering dexmedetomidine between responders and non-responders over a short (=24 h) and lengthy (>24 h) period. Results: A total of 84 patients were analyzed who received dexmedetomidine. The longest possible duration of dexmedetomidine administration was 24.7 days and 7.8 days, respectively. Compared to the first 24 h, the number of patients who needed more sedatives or analgesics was not increasing beyond that time. In the first 24 h and after the first 24 h, 35 out of 84 patients (41.2%) and 22 out of 84 patients (26.3%), respectively, needed more sedatives; in the first 24 h and after the first 24 h, 22 out of 84 patients (26.0%) and 18 out of 84 patients (21.4%) needed more analgesics. Conclusion: The safety and effectiveness of dexmedetomidine were similar across the demographic factors in this study. The interindividual variability due to pharmacokinetic parameters can be further studied along with pharmacogenomic factors that may cause the difference in the responses to dexmedetomidine use. [ABSTRACT FROM AUTHOR]

Background: Mechanical ventilation is essential for managing acute respiratory failure, but traditional methods of assessing oxygenation, like the PaO2/FiO2 ratio, pose challenges due to invasiveness and cost. Objective: This single-centre prospective observational study aimed to assess the potential of the non-invasive Oxygen Saturation Index (OSI), utilising SpO2 measurements, to diagnose hypoxemia in mechanically ventilated adults. The study sought to establish correlations between OSI, oxygenation index (OI), PaO2/FiO2 ratio and SpO2/FiO2 ratio. Methods: From August 2022 to July 2023, data was collected from 1055 mechanically ventilated intensive care unit patients. Statistical analysis included correlation tests, receiver operating curve (ROC) analysis and cut-off value determination for hypoxemia diagnosis. Results: We found that the P/F ratio had a statistically significant negative correlation with OI (correlation coefficient -0.832, P value: 0.000 in hypoxemic group and correlation coefficient -0.888, P value: 0.000 in the non-hypoxemic group), and OSI (correlation coefficient -0.746, P value: 0.000 in hypoxemic group and correlation coefficient -0.629, P value: 0.000 in non-hypoxemic group) and has a positive correlation with P/F ratio (correlation coefficient 0.92, P value: 0.000 in hypoxemic group and correlation coefficient -0.67, P value: 0.000 in non-hypoxemic group). OI and OSI had a statistically significant correlation (correlation coefficient 0.955, P value: 0.000 in hypoxemic group and correlation coefficient 0.815, P value: 0.000 in non-hypoxemic group). on ROC analysis P/F ratio was the most accurate in predicting hypoxia followed by OI and OSI. with a cut-off value, of OI being 7.07, and that for OSI being 3.90, at an 80% sensitivity level to diagnose hypoxemia. Conclusion: OSI can serve as a dependable surrogate for OI, simplifying ARDS severity assessment. The P/F ratio is the most accurate predictor of hypoxia. Further research, especially in larger multicentre studies, is needed to validate these findings and explore the long-term clinical implications of using OSI for oxygenation monitoring in mechanically ventilated patients. [ABSTRACT FROM AUTHOR]

Background: Large‐scale observational studies have summarized transfusion practice using traditional measures of central tendency (e.g., the mean hemoglobin concentration at the time of transfusion). However, the mean hemoglobin concentration fails to identify specific hemoglobin concentration thresholds that drive practice. In the following brief report, we propose a novel measure of "practice discontinuity" that identifies specific practice‐defining hemoglobin thresholds. Study Design and Methods: We used the PINC AI Database (2016–2022) to identify adult patients admitted to an intensive care unit with at least one hemoglobin concentration measurement. For each day that hemoglobin was measured, we identified whether the patient received a red blood cell transfusion using hospital charge codes. We defined the "practice discontinuity" measure as the hemoglobin concentration at which there was the largest increase in transfusion use going from a higher to an incrementally lower hemoglobin concentration. We also calculated the mean and median pretransfusion hemoglobin concentrations. Results: We identified 1,298,367 patients and 4,905,839 patient‐days for inclusion. RBC transfusion occurred in a total of 530,654 (10.8%) patient‐days. The overall pre‐transfusion mean and median hemoglobin concentrations were 8.4 and 8.0 g/dL, respectively. The practice discontinuity measure identified 7.0 g/dL as the hemoglobin concentration at which transfusion use increased the most, from 46.6% of patient‐days at a concentration of 7.0 g/dL to 74.8% of patient‐days at a concentration of 6.9 g/dL. Discussion: We propose that future studies of red blood cell transfusion practice consider inclusion of the practice discontinuity measure to more fully summarize clinical practice. [ABSTRACT FROM AUTHOR]

Patient sex affects treatment and outcomes in critical illness. Previous studies of sex differences in critical illness compared female and male patients. In this study, we describe the group of patients classified as a third sex admitted to ICUs in Australia and New Zealand. What are the admission characteristics and outcomes of ICU patients classified as belonging to a third sex group compared with patients classified as female or male? Retrospective observational study of admissions to 200 ICUs, recorded in the Australian and New Zealand Intensive Care Society's Adult Patient Database from 2018 to 2022. We undertook mixed effect logistic regression to compare hospital mortality across the sex groups, adjusted for illness severity, diagnosis, treatment limitation, year, and hospital. We examined 892,161 admissions, of whom 525 (0.06%) were classified as third sex. Patients classified as third sex were represented across all diagnostic categories, jurisdictions, and hospital types. On average, they were younger than the groups classified as female (59.2 ± 20.0 vs 61.3 ± 18.4 years; P =.02) or male (63.2 ± 16.7 years; P <.001), respectively. Patients classified as third sex were more likely to be admitted after orthopedic surgery (10.1% third sex admissions [95% CI, 7.7%-13.0%]; 6.2% female [95% CI, 6.1%-6.3%]; 4.8% male [95% CI, 4.7%-4.9%]) and drug overdose (8.8% third sex admissions [95% CI, 6.5%-11.5%]; 4.2% female [95% CI, 4.1%-4.2%]; 3.1% male [95% CI, 3.0%-3.1%]). There was no difference in the adjusted hospital mortality of patients classified as third sex compared with the other groups. Patients classified as third sex composed a small minority group of adult ICU patients. This group had a different diagnostic case mix but similar outcomes to the groups classified as female or male. Further characterizing a third sex group will require improved processes for recording sex and gender in health records. [Display omitted] [ABSTRACT FROM AUTHOR]

Objectives: To assess the impact of urinary incontinence (UI) on health outcomes over the entire spectrum of acute stroke severity (National Institutes of Health Stroke Scale [NIHSS] scores: 0–42), due to a paucity of data on patients with milder strokes. Patients and Methods: Data were prospectively collected (2014–2016) from the Sentinel Stroke National Audit Programme (1593 men, 1591 women; mean [SD] age 76.8 [13.3] years) admitted to four UK hyperacute stroke units (HASUs). Relationships between variables were assessed by multivariable logistic regression. Data were adjusted for age, sex, comorbidities, pre‐stroke disability and intra‐cranial haemorrhage, and presented as odds ratios with 95% confidence intervals. Results: Amongst patients with no symptoms or a minor stroke (NIHSS scores of 0–4), compared to patients without UI, patients with UI had significantly greater risks of poor outcomes including: in‐hospital mortality; disability at discharge; in‐hospital pneumonia; urinary tract infection within 7 days of admission; prolonged length of stay on the HASU; palliative care by discharge; activity of daily living (ADL) support, and new discharge to care home. In patients with more moderate stroke (NIHSS score of 5–15) the same outcomes were identified; being at greater risk for patients with UI, except for palliative care by discharge and ADL support. With the highest stroke severity group (NIHSS score of 16–48) all outcomes were identified except in‐patient mortality, pneumonia, and ADL support. However, odds ratios diminished as NIHSS scores increased. Conclusions: Urinary incontinence is a useful indicator of poor short‐term outcomes in older patients with an acute stroke, but irrespective of stroke severity. This provides valuable information to healthcare professionals to identify at‐risk individuals. [ABSTRACT FROM AUTHOR]

Background/Aim. Patients in intensive care units (ICUs) often exhibit disturbances in the concentration of thyroid hormones (THs), even if they had no previous thyroid disorders. The aim of the study was to determine whether there is a correlation between THs and the survival rate in the ICU and whether these hormones have predictive capability for mortality rate assessment. Methods. The study included 41 patients (23 women and 18 men) divided into two groups: survivors (70.7%) and non-survivors (29.3%). In peripheral blood samples taken within the first 24 hrs after ICU admission, TH levels were measured: triiodothyronine (T3), thyroxine (T4), free T3 (FT3), free T4 (FT4), and thyroid stimulating hormone (TSH), as well as procalcitonin (PCT). The Sequential Organ Failure Assessment Score (SOFAS) was calculated for each patient. Results. A statistically significant difference between the study groups (survivor vs. non-survivor patients, p < 0.05) was found for PCT, SOFAS, T3, T4, and FT4. The area under the receiver operating characteristic (ROC) curve (AUC) – (AUROC) for the SOFAS was 0.991 [95% confidence in terval (CI): 0.898–1.000, p < 0.001], for T3 was 0.727 (95% CI: 0.566–0.854, p = 0.0097), for T4 was 0.793 (95% CI: 0.638–0.903, p = 0.0008), for FT3 was 0.707 (95% CI: 0.544–0.8389, p = 0.0299), and for FT4 was 0.795 (95% CI: 0.640–0.904, p = 0.0005). Compared to other parameters, T3 had higher sensitivity (91.67%), FT4 had higher specificity (93.10%), while SOFAS had both the highest sensitivity (91.67%) and specificity (96.55%) in relation to all other tested parameters. Multiple linear regression analysis showed that FT4 and T4 were significant predictors of survival time (β = -0.362, p = 0.012 and β = -0.356, p = 0.014, respectively). Conclusion. Among all examined THs, only FT4 and T4 showed strong predictive potential for assessing mortality in ICU patients. This study has highlighted the significance of assessing THs levels in critically ill patients. This is crucial because it opens the possibility of implementing specific therapies to rectify issues stemming from hormonal deficiencies. [ABSTRACT FROM AUTHOR]