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BACKGROUND: Rezafungin is an echinocandin approved in the US and EU to treat candidaemia and/or invasive candidiasis. This post-hoc, pooled analysis of the Phase 2 STRIVE and Phase 3 ReSTORE trials assessed rezafungin versus caspofungin in patients with candidaemia and/or invasive candidiasis (IC) in the intensive care unit (ICU) at randomisation. METHODS: STRIVE and ReSTORE were randomised double-blind trials in adults with systemic signs and mycological confirmation of candidaemia and/or IC in blood or a normally sterile site ≤ 96 h before randomisation. Data were pooled for patients in the ICU at randomisation who received intravenous rezafungin (400 mg loading dose then 200 mg once weekly) or caspofungin (70 mg loading dose then 50 mg once daily) for ≤ 4 weeks. Outcomes were Day 30 all-cause mortality (primary outcome), Day 5 and 14 mycological eradication, time to negative blood culture, mortality attributable to candidaemia/invasive candidiasis, safety, and pharmacokinetics. RESULTS: Of 294 patients in STRIVE/ReSTORE, 113 were in the ICU at randomisation (rezafungin n = 46; caspofungin n = 67). At baseline, ~ 30% of patients in each group had impaired renal function and/or an Acute Physiologic Assessment and Chronic Health Evaluation II score ≥ 20. One patient (in the caspofungin group) was neutropenic at baseline. Day 30 all-cause mortality was 34.8% for rezafungin versus 25.4% for caspofungin. Day 5 and 14 mycological eradication was 78.3% and 71.7% for rezafungin versus 59.7% and 65.7% for caspofungin, respectively. Median time to negative blood culture was 18 (interquartile range, 12.6-43.0) versus 38 (interquartile range, 15.9-211.3) h for rezafungin versus caspofungin (stratified log-rank P = 0.001; nominal, not adjusted for multiplicity). Candidaemia/IC-attributable deaths occurred in two rezafungin patients versus one caspofungin patient. Safety profiles were similar between groups. Overall, 17.4% (rezafungin) versus 29.9% (caspofungin) of patients discontinued due to treatment-emergent adverse events. Rezafungin exposure following the initial 400-mg dose was comparable between patients in the ICU at randomisation (n = 50) and non-ICU patients (n = 117). CONCLUSIONS: Rezafungin was well tolerated and efficacious in critically ill, mainly non-neutropenic patients with candidaemia and/or IC. This analysis provides additional insights into the efficacy and safety of rezafungin in the ICU population.

The Brazilian Amazon is a vast area with limited health care resources. To assess the epidemiology of critically ill acute kidney injury (AKI) patients in this area, a prospective cohort study of 1029 adult patients of the three intensive care units (ICUs) of Rio Branco city, the capital of Acre state, were evaluated from February 2014 to February 2016. The incidence of AKI was 53.3%. Risk factors for AKI included higher age, nonsurgical patients, admission to the ICU from the ward, higher Acute Physiology and Chronic Health Evaluation (APACHE) II scores at ICU admission, and positive fluid balance > 1500 ml/24 hours in the days before AKI development in the ICU, with aOR of 1.3 (95% CI 1.03-1.23), 1.47 (95% CI 1.07-2.03), 1.96 (95% CI 1.40-2.74), 1.05 (95% CI 1.03-1.08) for each unit increase, and 1.62 (95% CI 1.16-2.26), respectively. AKI was associated with higher ICU mortality (aOR 2.03, 95% CI 1.29-3.18). AKI mortality was independently associated with higher age, nonsurgical patients, sepsis at ICU admission, presence of shock or use of vasoactive drugs, mechanical ventilation and mean positive fluid balance in the ICU > 1500 ml/24 hours, both during ICU follow-up, with aOR 1.27 (95% CI 1.14-1.43) for each 10-year increase, 1.64 (95% CI 1.07-2.52), 2.35 (95% CI 1.14-4.83), 1.88 (95% CI 1.03-3.44), 6.73 (95% CI 4.08-11.09), 2.31 (95% CI 1.52-3.53), respectively. Adjusted hazard ratios for AKI mortality 30 and 31-180 days after ICU discharge were 3.13 (95% CI 1.84-5.31) and 1.69 (95% CI 0.99-2.90), respectively. AKI incidence was strikingly high among critically ill patients in the Brazilian Amazon. The AKI etiology, risk factors and outcomes were similar to those described in high-income countries, but mortality rates were higher.

INTRODUCTION: Poor communication about serious injury in older adults can lead to treatment that is inconsistent with patient preferences, create conflict and strain healthcare resources. We developed a communication intervention called Best Case/Worst Case-intensive care unit (ICU) that uses daily scenario planning, that is, a narrative description of plausible futures, to support prognostication and facilitate dialogue among patients, their families and the trauma ICU team. This article describes a protocol for a multisite, randomised, stepped-wedge study to test the effectiveness of the intervention on the quality of communication (QOC) in the ICU. METHODS AND ANALYSIS: We will follow all patients aged 50 and older admitted to the trauma ICU for 3 or more days after a serious injury at eight high-volume level 1 trauma centres. We aim to survey one family or like family member per eligible patient 5-7 days following their loved ones admission and clinicians providing care in the trauma ICU. Using a stepped-wedge design, we will use permuted block randomisation to assign the timing for each site to begin implementation of the intervention and routine use of the Best Case/Worst Case-ICU tool. We will use a linear mixed-effects model to test the effect of the tool on family-reported QOC (using the QOC scale) as compared with usual care. Secondary outcomes include the effect of the tool on reducing clinician moral distress (using the Measure of Moral Distress for Healthcare Professionals scale) and patients length of stay in the ICU. ETHICS AND DISSEMINATION: Institutional review board (IRB) approval was granted at the University of Wisconsin, and all study sites ceded review to the primary IRB. We plan to report results in peer-reviewed publications and national meetings. TRIAL REGISTRATION NUMBER: NCT05780918.

IMPORTANCE: Treatment for intracranial pressure (ICP) has been increasingly informed by machine learning (ML)-derived ICP waveform characteristics. There are gaps, however, in understanding how ICP monitor type may bias waveform characteristics used for these predictive tools since differences between external ventricular drain (EVD) and intraparenchymal monitor (IPM)-derived waveforms have not been well accounted for. OBJECTIVES: We sought to develop a proof-of-concept ML model differentiating ICP waveforms originating from an EVD or IPM. DESIGN, SETTING, AND PARTICIPANTS: We examined raw ICP waveform data from the ICU physiology cohort within the prospective Transforming Research and Clinical Knowledge in Traumatic Brain Injury multicenter study. MAIN OUTCOMES AND MEASURES: Nested patient-wise five-fold cross-validation and group analysis with bagged decision trees (BDT) and linear discriminant analysis were used for feature selection and fair evaluation. Nine patients were kept as unseen hold-outs for further evaluation. RESULTS: ICP waveform data totaling 14,110 hours were included from 82 patients (EVD, 47; IPM, 26; both, 9). Mean age, Glasgow Coma Scale (GCS) total, and GCS motor score upon admission, as well as the presence and amount of midline shift, were similar between groups. The model mean area under the receiver operating characteristic curve (AU-ROC) exceeded 0.874 across all folds. In additional rigorous cluster-based subgroup analysis, targeted at testing the resilience of models to cross-validation with smaller subsets constructed to develop models in one confounder set and test them in another subset, AU-ROC exceeded 0.811. In a similar analysis using propensity score-based rather than cluster-based subgroup analysis, the mean AU-ROC exceeded 0.827. Of 842 extracted ICP features, 62 were invariant within every analysis, representing the most accurate and robust differences between ICP monitor types. For the nine patient hold-outs, an AU-ROC of 0.826 was obtained using BDT. CONCLUSIONS AND RELEVANCE: The developed proof-of-concept ML model identified differences in EVD- and IPM-derived ICP signals, which can provide missing contextual data for large-scale retrospective datasets, prevent bias in computational models that ingest ICP data indiscriminately, and control for confounding using our models output as a propensity score by to adjust for the monitoring method that was clinically indicated. Furthermore, the invariant features may be leveraged as ICP features for anomaly detection.

OBJECTIVE: To evaluate social drivers of health and how they impact pediatric oncology patients clinical outcomes during pediatric intensive care unit (PICU) admission via correlation with patient ZIP codes. METHODS: Demographic, clinical, and outcome variables from Virtual Pediatric Systems®, LLC for oncology patients (2009-2021) in California PICUs (excluding postoperative) using 3-digit ZIP Codes with social drivers of health variables linguistic isolation, poverty, race/ethnicity, and education abstracted from American Community Survey data for 3-digit ZIP Codes using the Environmental Protection Agencys EJScreen tool. Outcomes of length of stay (LOS), mortality, acuity scores, were compared with social variables. RESULTS: Positive correlation between mortality and minority racial groups (Hispanic/Latino) across ZIP Codes (correlation coefficients of 0.45 (95% CI: 0.22-0.64, p

OBJECTIVE: There is widespread overuse of antibiotics in neonatal intensive care units (NICUs). The objective of this study was to safely reduce antibiotic use in participating NICUs by targeting early-onset sepsis (EOS) management. STUDY DESIGN: Twenty-eight NICUs participated in this statewide multicenter antibiotic stewardship quality improvement collaborative. The primary aim was to reduce the total monthly mean antibiotic utilization rate (AUR) by 25% in participant NICUs. RESULT: Aggregate AUR was reduced by 15.3% (p

OBJECTIVES: To describe the utilization of early ketamine use among patients mechanically ventilated for COVID-19, and examine associations with in-hospital mortality and other clinical outcomes. DESIGN: Retrospective cohort study. SETTING: Six hundred ten hospitals contributing data to the Premier Healthcare Database between April 2020 and June 2021. PATIENTS: Adults with COVID-19 and greater than or equal to 2 consecutive days of mechanical ventilation within 5 days of hospitalization. INTERVENTION: The exposures were early ketamine use initiated within 2 days of intubation and continued for greater than 1 day. MEASUREMENTS: Primary was hospital mortality. Secondary outcomes included length of stay (LOS) in the hospital and ICUs, ventilator days, vasopressor days, renal replacement therapy (RRT), and total hospital cost. The propensity score matching analysis was used to adjust for confounders. MAIN RESULTS: Among 42,954 patients, 1,423 (3.3%) were exposed to early ketamine use. After propensity score matching including 1,390 patients in each group, recipients of ketamine infusions were associated with higher hospital mortality (52.5% vs. 45.9%, risk ratio: 1.14, [1.06-1.23]), longer median ICU stay (13 vs. 12 d, mean ratio [MR]: 1.15 [1.08-1.23]), and longer ventilator days (12 vs. 11 d, MR: 1.19 [1.12-1.27]). There were no associations for hospital LOS (17 [10-27] vs. 17 [9-28], MR: 1.05 [0.99-1.12]), vasopressor days (4 vs. 4, MR: 1.04 [0.95-1.14]), and RRT (22.9% vs. 21.7%, RR: 1.05 [0.92-1.21]). Total hospital cost was higher (median $72,481 vs. $65,584, MR: 1.11 [1.05-1.19]). CONCLUSIONS: In a diverse sample of U.S. hospitals, about one in 30 patients mechanically ventilated with COVID-19 received ketamine infusions. Early ketamine may have an association with higher hospital mortality, increased total cost, ICU stay, and ventilator days, but no associations for hospital LOS, vasopressor days, and RRT. However, confounding by the severity of illness might occur due to higher extracorporeal membrane oxygenation and RRT use in the ketamine group. Further randomized trials are needed to better understand the role of ketamine infusions in the management of critically ill patients.

OBJECTIVE: Despite limited safety and efficacy data, inhaled corticosteroids (ICS) are prescribed to premature infants in the neonatal intensive care unit (NICU). We examined contemporary use and risk factors for ICS use in the NICU. STUDY DESIGN: Infants

BACKGROUND: Cerebral vasospasm (CV) is a feared complication which occurs after 20-40% of subarachnoid haemorrhage (SAH). It is standard practice to admit patients with SAH to intensive care for an extended period of resource-intensive monitoring. We used machine learning to predict CV requiring verapamil (CVRV) in the largest and only multi-center study to date. METHODS: Patients with SAH admitted to UCLA from 2013 to 2022 and a validation cohort from VUMC from 2018 to 2023 were included. For each patient, 172 unique intensive care unit (ICU) variables were extracted through the primary endpoint, namely first verapamil administration or no verapamil. At each institution, a light gradient boosting machine (LightGBM) was trained using five-fold cross validation to predict the primary endpoint at various hospitalization timepoints. FINDINGS: A total of 1750 patients were included from UCLA, 125 receiving verapamil. LightGBM achieved an area under the ROC (AUC) of 0.88 > 1 week in advance and ruled out 8% of non-verapamil patients with zero false negatives. Our models predicted no CVRV vs CVRV within three days vs CVRV after three days with AUCs = 0.88, 0.83, and 0.88, respectively. From VUMC, 1654 patients were included, 75 receiving verapamil. VUMC predictions averaged within 0.01 AUC points of UCLA predictions. INTERPRETATION: We present an accurate and early predictor of CVRV using machine learning with multi-center validation. This represents a significant step towards optimized clinical management and resource allocation in patients with SAH. FUNDING: Robert E. Freundlich is supported by National Center for Advancing Translational Sciences federal grant UL1TR002243 and National Heart, Lung, and Blood Institute federal grant K23HL148640; these funders did not play any role in this study. The National Institutes of Health supports Vanderbilt University Medical Center which indirectly supported these research efforts. Neither this study nor any other authors personally received financial support for the research presented in this manuscript. No support from pharmaceutical companies was received.

BACKGROUND: Language in nonmedical data sets is known to transmit human-like biases when used in natural language processing (NLP) algorithms that can reinforce disparities. It is unclear if NLP algorithms of medical notes could lead to similar transmissions of biases. RESEARCH QUESTION: Can we identify implicit bias in clinical notes, and are biases stable across time and geography? STUDY DESIGN AND METHODS: To determine whether different racial and ethnic descriptors are similar contextually to stigmatizing language in ICU notes and whether these relationships are stable across time and geography, we identified notes on critically ill adults admitted to the University of California, San Francisco (UCSF), from 2012 through 2022 and to Beth Israel Deaconess Hospital (BIDMC) from 2001 through 2012. Because word meaning is derived largely from context, we trained unsupervised word-embedding algorithms to measure the similarity (cosine similarity) quantitatively of the context between a racial or ethnic descriptor (eg, African-American) and a stigmatizing target word (eg, nonco-operative) or group of words (violence, passivity, noncompliance, nonadherence). RESULTS: In UCSF notes, Black descriptors were less likely to be similar contextually to violent words compared with White descriptors. Contrastingly, in BIDMC notes, Black descriptors were more likely to be similar contextually to violent words compared with White descriptors. The UCSF data set also showed that Black descriptors were more similar contextually to passivity and noncompliance words compared with Latinx descriptors. INTERPRETATION: Implicit bias is identifiable in ICU notes. Racial and ethnic group descriptors carry different contextual relationships to stigmatizing words, depending on when and where notes were written. Because NLP models seem able to transmit implicit bias from training data, use of NLP algorithms in clinical prediction could reinforce disparities. Active debiasing strategies may be necessary to achieve algorithmic fairness when using language models in clinical research.

In alignment with previous literature, NICU parents reported experiencing racism and NICU staff reported witnessing racism in the NICU. Our study also uniquely describes personal experiences with racism by staff in the NICU. NICU staff reported witnessing and experiencing racism more often than parents reported. Black staff reported witnessing and experiencing more racism than white staff. Differences in reporting is likely influenced by variations in lived experience, social identities, psychological safety, and levels of awareness. Future studies are necessary to prevent and accurately measure racism in the NICU.

BACKGROUND: Posttraumatic stress (PTS) and anxiety are common mental health problems among parents of babies admitted to a neonatal unit (NNU). This review aimed to identify sociodemographic, pregnancy and birth, and psychological factors associated with PTS and anxiety in this population. METHOD: Studies published up to December 2022 were retrieved by searching Medline, Embase, PsychoINFO, Cumulative Index to Nursing and Allied Health electronic databases. The modified Newcastle-Ottawa Scale for cohort and cross-sectional studies was used to assess the methodological quality of included studies. This review was pre-registered in PROSPERO (CRD42021270526). RESULTS: Forty-nine studies involving 8,447 parents were included; 18 studies examined factors for PTS, 24 for anxiety and 7 for both. Only one study of anxiety factors was deemed to be of good quality. Studies generally included a small sample size and were methodologically heterogeneous. Pooling of data was not feasible. Previous history of mental health problems (four studies) and parental perception of more severe infant illness (five studies) were associated with increased risk of PTS, and had the strongest evidence. Shorter gestational age (≤ 33 weeks) was associated with an increased risk of anxiety (three studies) and very low birth weight (

OBJECTIVE: Selective serotonin reuptake inhibitor (SSRI) use is common in pregnancy. It is associated with delayed neonatal adaptation. Most previous studies have not adjusted for the severity of maternal mental health disorders or examined the impact of SSRI type and dosage. We examined whether treatment with SSRIs in late pregnancy (after 20 weeks) is associated with delayed neonatal adaptation independent of maternal depression and anxiety. DESIGN, SETTING AND PATIENTS: Retrospective population-based birth cohort of 280 090 term infants born at 15 Kaiser Permanente Northern California hospitals, 2011-2019. Individual-level pharmacy, maternal, pregnancy and neonatal data were obtained from electronic medical records. EXPOSURE: Dispensed maternal SSRI prescription after 20 weeks of pregnancy. MAIN OUTCOME MEASURES: Delayed neonatal adaptation defined as a 5 min Apgar score ≤5, resuscitation at birth or admission to a neonatal intensive care unit for respiratory support. Secondary outcomes included each individual component of the primary outcome and more severe neonatal outcomes (pulmonary hypertension, hypoxic-ischaemic encephalopathy and seizures). RESULTS: 7573 (2.7%) infants were exposed to SSRIs in late pregnancy. Delayed neonatal adaptation occurred in 11.2% of exposed vs 4.4% of unexposed infants (relative risk 2.52 (95% CI 2.36 to 2.70)). After multivariable adjustment, there was an association between SSRI exposure and delayed neonatal adaptation (adjusted OR 2.14 (95% CI 1.96 to 2.32)). This association was dose dependent. Escitalopram and fluoxetine were associated with the highest risk of delayed neonatal adaptation. CONCLUSIONS: Infants exposed to SSRIs have increased risks of delayed adaptation in a type and dose-dependent relationship, pointing toward a causal relationship.

The survival of preterm infants has steadily improved thanks to advances in perinatal and neonatal intensive clinical care. The focus is now on finding ways to improve morbidities, especially neurological outcomes. Although antenatal steroids and magnesium for preterm infants have become routine therapies, studies have mainly demonstrated short-term benefits for antenatal steroid therapy but limited evidence for impact on long-term neurodevelopmental outcomes. Further advances in neuroprotective and neurorestorative therapies, improved neuromonitoring modalities to optimize recruitment in trials, and improved biomarkers to assess the response to treatment are essential. Among the most promising agents, multipotential stem cells, immunomodulation, and anti-inflammatory therapies can improve neural outcomes in preclinical studies and are the subject of considerable ongoing research. In the meantime, bundles of care protecting and nurturing the brain in the neonatal intensive care unit and beyond should be widely implemented in an effort to limit injury and promote neuroplasticity. IMPACT: With improved survival of preterm infants due to improved antenatal and neonatal care, our focus must now be to improve long-term neurological and neurodevelopmental outcomes. This review details the multifactorial pathogenesis of preterm brain injury and neuroprotective strategies in use at present, including antenatal care, seizure management and non-pharmacological NICU care. We discuss treatment strategies that are being evaluated as potential interventions to improve the neurodevelopmental outcomes of infants born prematurely.

Intensive care unit (ICU) nurses frequently manually titrate norepinephrine to maintain a predefined mean arterial pressure (MAP) target after high-risk surgery. However, achieving this task is often suboptimal. We have developed a closed-loop vasopressor (CLV) controller to better maintain MAP within a narrow range. After ethical committee approval, fifty-three patients admitted to the ICU following high-risk abdominal surgery were randomized to CLV or manual norepinephrine titration. In both groups, the aim was to maintain MAP in the predefined target of 80-90 mmHg. Fluid administration was standardized in the two groups using an advanced hemodynamic monitoring device. The primary outcome of our study was the percentage of time patients were in the MAP target. Over the 2-hour study period, the percentage of time with MAP in target was greater in the CLV group than in the control group (median: IQR25-75: 80 [68-88]% vs. 42 [22-65]%), difference 37.2, 95% CI (23.0-49.2); p  90 mmHg was not statistically different between groups. In patients admitted to the ICU after high-risk abdominal surgery, closed-loop control of norepinephrine infusion better maintained a MAP target of 80 to 90 mmHg and significantly decreased postoperative hypotensive when compared to manual norepinephrine titration.

INTRODUCTION: Patients experience high symptom burden during critical care hospitalization and mechanical ventilation. Medications are of limited effectiveness and are associated with increased morbidity such as delirium and long-term cognitive and psychological impairments. Music-based interventions have been used for pain and anxiety management in critical care but remain understudied in terms of music selection and range of symptoms. This study aimed to describe the ways in which a diverse sample of critically ill adults used personalized music listening and their perceptions of the effects of music listening on symptom experience after critical injury. METHODS: Semi-structured interviews (N = 14) of adult patients, families and friends who were provided with personalized music in an urban, academic, neurotrauma intensive care unit were collected and analyzed with grounded theory methodology. Open coding of transcripts, field notes and memos was performed using Atlas.ti.9.1. Recruitment and data collection were deemed complete once thematic saturation was achieved. RESULTS: We identified 6 uses of personalized music listening in critical care: 1) Restoring consciousness; 2) Maintaining cognition; 3) Humanizing the hospital experience; 4) Providing a source of connection; 5) Improving psychological wellbeing; and 6) Resolving the problems of silence. Patients used music to address psychological experiences of loneliness, fear, confusion, and loss of control. Personalized music helped patients maintain their identity and process their trauma. Additional benefits of music included experiencing pleasure, hope, resilience, and feelings of normalcy. Patients disliked being sedated and used music to wake up. Findings also highlighted the problem of the lack of meaningful stimulation in critical care. CONCLUSION: Critically injured adults used personalized music to achieve psychological and cognitive homeostasis during critical care hospitalization. These results can inform future studies designed to explore the use of music-based interventions to prevent and treat the cognitive and emotional morbidity of critical care.

INTRODUCTION: Sepsis is a major cause of morbidity and mortality worldwide. In the updated, 2016 Sepsis-3 criteria, sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection, where organ dysfunction can be represented by an increase in the Sequential Organ Failure Assessment (SOFA) score of 2 points or more. We sought to apply the Sepsis-3 criteria to characterise the septic cohort in the Amsterdam University Medical Centres database (Amsterdam UMCdb). METHODS: We examined adult intensive care unit (ICU) admissions in the Amsterdam UMCdb, which contains de-identified data for patients admitted to a mixed surgical-medical ICU at a tertiary academic medical centre in the Netherlands. We operationalised the Sepsis-3 criteria, defining organ dysfunction as an increase in the SOFA score of 2 points or more, while infection was defined as a new course of antibiotics or an escalation in antibiotic therapy, with at least one antibiotic given intravenously. Patients with sepsis were determined to be in septic shock if they additionally required the use of vasopressors and had a lactate level >2 mmol/L. RESULTS: We identified 18,221 ICU admissions from 16,408 patients in our cohort. There were 6,312 unique sepsis episodes, of which 30.2% met the criteria for septic shock. A total of 4,911/6,312 sepsis (77.8%) episodes occurred on ICU admission. Forty-seven percent of emergency medical admissions and 36.7% of emergency surgical admissions were for sepsis. Overall, there was a 12.5% ICU mortality rate; patients with septic shock had a higher ICU mortality rate (38.4%) than those without shock (11.4%). CONCLUSIONS: We successfully operationalised the Sepsis-3 criteria to the Amsterdam UMCdb, allowing the characterization and comparison of sepsis epidemiology across different centres.

The primary ethical principle guiding general medical practice is autonomy. However, in mass casualty (MASCAL) or disaster scenarios, the principles of beneficence and justice become of foremost concern. Despite multiple reviews, publications, and training courses available to prepare for a MASCAL incident, a minority of physicians and healthcare providers are abreast of these. In this review, we describe several MASCAL scenarios and their associated ethical, moral, and medicolegal quandaries in attempts to curb potential future misadventures.

OBJECTIVE: This study investigates how team cognition occurs in care transitions from operating room (OR) to intensive care unit (ICU). We then seek to understand how the sociotechnical system and team cognition are related. BACKGROUND: Effective handoffs are critical to ensuring patient safety and have been the subject of many improvement efforts. However, the types of team-level cognitive processing during handoffs have not been explored, nor is it clear how the sociotechnical system shapes team cognition. METHOD: We conducted this study in an academic, Level 1 trauma center in the Midwestern United States. Twenty-eight physicians (surgery, anesthesia, pediatric critical care) and nurses (OR, ICU) participated in semi-structured interviews. We performed qualitative content analysis and epistemic network analysis to understand the relationships between system factors, team cognition in handoffs and outcomes. RESULTS: Participants described three team cognition functions in handoffs-(1) information exchange, (2) assessment, and (3) planning and decision making; information exchange was mentioned most. Work system factors influenced team cognition. Inter-professional handoffs facilitated information exchange but included large teams with diverse backgrounds communicating, which can be inefficient. Intra-professional handoffs decreased team size and role diversity, which may simplify communication but increase information loss. Participants in inter-professional handoffs reflected on outcomes significantly more in relation to system factors and team cognition (p < 0.001), while participants in intra-professional handoffs discussed handoffs as a task. CONCLUSION: Handoffs include team cognition, which was influenced by work system design. Opportunities for handoff improvement include a flexibly standardized process and supportive tools/technologies. We recommend incorporating perspectives of the patient and family in future work.

We created a concise nurse-driven delirium reduction workflow with the aim of reducing delirium rates and length of stay for hospitalized adults. Our nurse-driven workflow included five evidence-based daytime sunrise interventions (patient room lights on, blinds up, mobilization/out-of-bed, water within patients reach and patient awake) and five nighttime turndown interventions (patient room lights off, blinds down, television off, noise reduction and pre-set bedtime). Interventions were also chosen because fidelity could be quickly monitored twice daily without patient interruption from outside the room. To evaluate the workflow, we used an interrupted time series study design between 06/01/17 and 05/30/22 to determine if the workflow significantly reduced the units delirium rate and average length of stay. Our workflow is feasible to implement and monitor and initially significantly reduced delirium rates but not length of stay. However, the reduction in delirium rates were not sustained following the emergence of the COVID-19 pandemic.

Driving pressure (DP) is a marker of severity of lung injury in patients with acute respiratory distress syndrome (ARDS) and has a strong association with outcome. However, it is uncertain whether limiting DP can reduce the mortality of patients with acute hypoxemic respiratory failure (AHRF). Therefore, this study aimed to determine the correlation between the initial DP setting and the clinical outcomes of patients with AHRF upon their initial admission to the intensive care unit (ICU). The Medical Information Mart for Intensive Care IV (MIMIC-IV) database was used to search the data of patients with AHRF, with 180-day mortality representing the primary outcome. Multiple regression analysis was subsequently performed to evaluate the initial DP and 180-day mortality association. The reliability of the results was validated using restricted cubic splines and interaction studies. This study retrospectively analyzed data from 907 patients—581 (64.06%) in the survival group and 326 (35.94%) in the nonsurvival group (NSG)—who were followed up 180 days after admission. The results revealed that an elevated initial DP was significantly correlated with 180-day mortality (HR 1.071 (95% CI 1.040, 1.102)), especially when the initial DP exceeded 12 cmH2O. AHRF patients with an initial DP > 12 cmH2O had significantly greater mortality at 28 days (p = 0.0082), 90 days (p = 0.0083), and 180 days (p = 0.0039) than those with an initial DP ≤ 12 cmH2O. Among severe patients with AHRF, 180-day mortality was significantly greater in the group with an initial DP > 12 cmH2O than in the group with an initial DP ≤ 12 cmH2O (p = 0.029). The hospital length of stay (LOS) for patients with an initial DP < 12 cmH2O was significantly longer than that for those with an initial DP > 12 cmH2O (p = 0.029). Among patients with AHRF and an initial DP > 12 cmH2O, the survival group had a significantly longer LOS in the ICU than the NSG (p = 0.00026). The initial DP settings were correlated with 180-day mortality among patients with AHRF admitted to the ICU. Particularly for patients with AHRF, it is crucial to consider implementing early restrictive DP ventilation as a potential means to mitigate mortality, and close monitoring is essential to evaluate its impact. [ABSTRACT FROM AUTHOR]

Introduction: Using the COVID‐19 pandemic as an example of a national and international crisis, it has been possible to show how critical care nurses (CCNs) were affected by their work situation with impact on health and wellbeing. This study sought out to investigate how CCNs stress was affected and to provide some answers as to how to react and organize care in a future crisis. The specific focus was CCNs' stressors related supervision of nurses untrained in intensive care and how these were handled in a salutogenic perspective. Aim: The aim of this study was to analyze CCNs' experiences of supervision of nurses without training in intensive care during the COVID‐19 pandemic, and to analyze these experiences with the help of the salutogenic concept sense of coherence. Materials and Methods: The phenomena under study were explored during the years of 2021–2022 through in‐depth interviews and interpreted using deductive content analysis. Results: By analyzing CCNs experiences of supervising nurses without training in intensive care with the lens of sense of coherence, it was possible to show in what way these concepts influenced how to cope with the demanding situation. Sense of coherence was influenced by the inevitable prioritization of patient care and nursing interventions. This prioritization caused moral distress, but was also enhanced or decreased by CCNs sense of coherence. Conclusion: When recruiting and introducing new personnel in a future crisis to any field of healthcare, but particularly to the intensive care, we would, on the basis of these findings, suggest that well‐established plans are vital for how to move personnel throughout the organization, and for how to introduce the field of intensive care. Plans for how to model care with the help of RNs without specialist training should be put in place. A communication plan for the organization is also of importance to enhance transparency. [ABSTRACT FROM AUTHOR]

Introduction Methods Results Conclusion The shared risk profiles for cancer and heart disease suggest many individuals with cancer may have an implantable cardioverter defibrillator (ICD). ICDs can have dramatic cancer end‐of‐life care implications including painful and distressing shocks. ICD prevalence and association with aggressive end‐of‐life care among individuals with breast, colorectal, and pancreatic cancer was evaluated using the Surveillance, Epidemiology, and End Results‐Medicare dataset.A total of 37,306 Medicare beneficiaries aged ≥66 years with stage 3 or 4 cancer who died between 2005 and 2016 were identified. ICD prevalence, ICD‐related care utilization that might present opportunities to discuss end‐of‐life implications and association with aggressive end‐of‐life care (>1 emergency department visit, intensive care unit admission, >1 hospitalization, terminal hospitalization, chemotherapy, and invasive or life‐extending procedures) in the last month of life was assessed using multivariable logistic regression.Among cancer decedents, 6% had an ICD. More individuals with an ICD (31%) died in the hospital than individuals without an ICD (25%; p < .001). Half (46%) of individuals with an ICD had device programming or interrogation visits that could be an opportunity for device discussion. In adjusted models, ICD presence was associated with higher odds of every indicator of aggressive end‐of‐life care other than chemotherapy.Many older cancer decedents in the United States had an ICD, and those with ICDs received more aggressive care at the end of life. Results suggest there are opportunities to discuss ICD and goals of care, raise awareness and encourage shared decision‐making for this population to ensure goal‐concordant care, and improve end‐of‐life care quality. [ABSTRACT FROM AUTHOR]

Purpose: Mobilisation is a common intervention in Intensive Care (ICU). However, few studies have explored the relationship between mobility levels and outcomes. This study assessed the association of the level of mobility on ICU discharge with discharge destination from the hospital and hospital length of stay. Materials and methods: A retrospective analysis of data from 522 patients admitted to a single UK general ICU who were ventilated for ≥5 days was performed. The level of mobility was assessed using the Manchester Mobility Score (MMS). Multivariable regression analysed demographic and clinical variables for the independence of association with discharge destination and hospital length of stay. Results: MMS ≥5 on ICU discharge was independently associated with discharge destination and hospital LOS (p < 0.001). Patients achieving MMS ≥5 on ICU discharge were more likely to be discharged home (OR 3.86 95% CI 2.1 to 6.9, p < 0.001), and had an 11.8 day shorter hospital LOS (95% CI −17.6 to −6.1, p < 0.001). Conclusions: The ability to step transfer to a chair (MMS ≥5) before ICU discharge was independently associated with discharge to usual residence and hospital LOS, irrespective of preadmission morbidity. Increasing the level of patient mobility at ICU discharge should be a key focus of rehabilitation interventions. IMPLICATIONS FOR REHABILITATION: Mobilisation in the Intensive Care Unit (ICU) is common practice, however studies to date have not evaluated the impact on acute hospital outcomes. Achieving the ability to step to a chair on ICU discharge is an important rehabilitation milestone, and is associated with a shorter hospital length of stay and being discharged home. Rehabilitation interventions in the ICU should be targeted at progressing patients towards this milestone. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the test-retest reliability and construct validity of the LCADL scale applied via online form in individuals after hospitalization for COVID-19. Methods: Methodological study. After hospitalization for COVID-19 individuals completed the LCADL via online form at two separate times. They also answered the post-COVID-19 Functional Status Scale (PCFS), dyspnea, fatigue, and health perception scales, modified Medical Research Council (MRCm), Short Form Health Survey 36 (SF-36). Hospitalization data were collected from the individual's medical record. Results: 104 individuals participated in the study (57 men, 45.2 ± 11.9 years). The LCADL showed moderately to high test-retest reliability (ICC: 0.73–0.86; p < 0.001), there was no difference in scores between test and retest (p > 0.05), the mean difference between the applications was smaller than the standard error of measurement and the internal consistency was adequate (Cronbach's α = 0.70–0.94). In addition, it demonstrated adequate construct validity, showing correlations with PCFS, dyspnea perception, fatigue and health scales, mMRC, SF-36, and length of stay in the Intensive Care Unit (p < 0.05). The LCADL as percentage of the total score presented a significant floor effect (25%). Conclusion: The LCADL applied online was reliable and valid for assessing limitations due to dyspnea in ADL in individuals after hospitalization for COVID-19. IMPLICATIONS FOR REHABILITATION: The London Chest Activity of Daily Living Scale applied online is a method of evaluation of dyspnea-related ADL limitations that is valid and reliable after hospitalization for COVID-19 and can be used both in the telerehabilitation environment and in-person rehabilitation; The online form provides a more sustainable means of data storage, since no paper is needed, and saves time during in-person rehabilitation. [ABSTRACT FROM AUTHOR]

Key Points: Question: Is an automated surface temperature management device effective in prevention of fever in patients with acute vascular brain injury, and does it improve functional outcomes compared with standard fever care? Findings: In this randomized clinical trial of 677 critically ill patients with stroke, temperature modulation significantly reduced daily mean fever burden compared with standard fever care (0.37 °C-hour vs 0.73 °C-hour), but there was no significant difference in functional outcomes at 3 months. Meaning: Fever prevention in patients with acute vascular brain injury using an automated surface temperature management device reduced fever burden but did not improve functional outcomes. Importance: Fever is associated with worse outcomes in patients with stroke, but whether preventing fever improves outcomes is unclear. Objective: To determine whether fever prevention after acute vascular brain injury is achievable and impacts functional outcome. Design, Setting, and Participants: Open-label randomized clinical trial with blinded outcome assessment that enrolled 686 of 1176 planned critically ill patients with stroke at 43 intensive care units in 7 countries from March 2017 to April 2021 (last date of follow-up was May 12, 2022). Intervention: Patients randomized to fever prevention (n = 339) were targeted to 37.0 °C for 14 days or intensive care unit discharge using an automated surface temperature management device. Standard care patients (n = 338) received standardized tiered fever treatment on occurrence of temperature of 38 °C or greater. Main Outcomes and Measures: Primary outcome was daily mean fever burden: the area under the temperature curve above 37.9 °C (total fever burden) divided by the total number of hours in the acute phase, multiplied by 24 hours (°C-hour). The principal secondary outcome was 3-month functional recovery by shift analysis of the 6-category modified Rankin Scale, which is scored from 0 (no symptoms) to 6 (death). Major adverse events included death, pneumonia, sepsis, and malignant cerebral edema. Results: Enrollment was stopped after a planned interim analysis demonstrated futility of the principal secondary end point. In total, 686 patients were enrolled, and 9 were consented but not randomized, leaving a primary analysis population of 677 patients (254 ischemic stroke, 223 intracerebral hemorrhage, 200 subarachnoid hemorrhage; 345 were female [51%]; median age, 62 years) with 433 (64%) completing the study through 12 months. Daily mean (SD) fever burden was significantly lower in the fever prevention group (0.37 [1.0] °C-hour; range, 0.0-8.0 °C-hour) compared with the standard care group (0.73 [1.1] °C-hour; range, 0.0-10.3 °C-hour) (difference, −0.35 [95% CI, −0.51 to −0.20]; P <.001). Between-group differences for the primary outcome by stroke subtype were −0.10 (95% CI, −0.35 to 0.15) for ischemic stroke, −0.50 (95% CI, −0.78 to −0.22) for intracerebral hemorrhage, and −0.52 (95% CI, −0.81 to −0.23) for subarachnoid hemorrhage (all P <.001 by Wilcoxon rank-sum test). There was no significant difference in functional recovery at 3 months (median modified Rankin Scale score, 4.0 vs 4.0, respectively; odds ratio for a favorable shift in functional outcome, 1.09 [95% CI, 0.81 to 1.46]; P =.54). Major adverse events occurred in 82.2% of participants in the fever prevention group vs 75.9% in the standard care group, including 33.8% vs 34.5% for infections, 14.5% vs 14.0% for cardiac disorders, and 24.5% vs 20.5% for respiratory disorders. Conclusions and Relevance: In patients with acute vascular brain injury, preventive normothermia using an automated surface temperature management device effectively reduced fever burden but did not improve functional outcomes. Trial Registration: ClinicalTrials.gov Identifier: NCT02996266 This clinical trial compares fever prevention targeted to 37.0 °C for 14 days vs standardized tiered fever treatment on functional outcomes in critically ill patients with stroke. [ABSTRACT FROM AUTHOR]

The document explores global responses to patient blood management practices, detailing routine screening, blood alternatives, interventions to reduce blood loss, and strategies to minimize inappropriate transfusions. Different countries face unique challenges and employ diverse approaches, reflecting varied healthcare systems. The implementation of a Patient Blood Management (PBM) program involves a multidisciplinary team and focuses on reducing blood demand through restrictive transfusion thresholds and monitoring adherence. The program's success lies in decreased blood usage in monitored areas, with challenges in regions lacking IT capabilities, and recommendations include simple measures like incorporating tranexamic acid into surgical protocols. [Extracted from the article]

ABSTRACT Aim Background Evaluation Key issues Conclusions Implications for clinical practice To identify factors protecting and hindering the well‐being of critical care nurses during the COVID‐19 pandemic.The unique work challenges of critical care nurses can undermine their professional and mental well‐being; as evidenced by the prevailing literature on burnout, compassion fatigue, and moral distress. The COVID‐19 pandemic has seen these professionals on the front lines and has raised many questions about professional well‐being. Identifying the factors that protect and hinder the well‐being of critical care nurses would help to develop the strategies necessary to reduce worrying phenomena associated with professional malaise.A systematic review was conducted using electronic databases including PubMed, CINAHL, Scopus, Cochrane, PsycINFO, and Web on Science.After full text analysis, 25 papers were included in the current systematic review. Factors influencing the well‐being of critical care nurses have been grouped into “Protective” and “Hindering.”This review shows that critical care nurses’ well‐being is influenced by factors like personal resilience and supportive work environments, which enhance their experience. Challenges include sociodemographic issues and the COVID‐19 pandemic's impact. Addressing these factors is crucial for their well‐being and the effectiveness of healthcare systems.The well‐being of nurses is intricately linked to the quality and security of patient care, ultimately influencing clinical outcomes. This review delves deeply into the multifaceted factors that affect the professional well‐being of critical care nurses during the COVID‐19 pandemic. Recognizing these elements is critical for directing health policy toward the development of initiatives that bolster healthcare workers’ welfare. Prioritizing the professional well‐being of nurses is imperative, as it is fundamental in mitigating the increasing inclination towards job turnover, a challenge that is profoundly impacting the healthcare sector. [ABSTRACT FROM AUTHOR]

With the large volume of data coming from implemented technologies and monitoring systems, intensive care units (ICUs) represent a key area for artificial intelligence (AI) application. Despite the last decade has been marked by studies focused on the use of AI in medicine, its application in mechanical ventilation management is still limited. Optimizing mechanical ventilation is a complex and high-stake intervention, which requires a deep understanding of respiratory pathophysiology. Therefore, this complex task might be supported by AI and machine learning. Most of the studies already published involve the use of AI to predict outcomes for mechanically ventilated patients, including the need for intubation, the respiratory complications, and the weaning readiness and success. In conclusion, the application of AI for the management of mechanical ventilation is still at an early stage and requires a cautious and much less enthusiastic approach. Future research should be focused on AI progressive introduction in the everyday management of mechanically ventilated patients, with the aim to explore the great potentiality of this tool. Plain Language Summary: The use of artificial intelligence for mechanical ventilation Artificial Intelligence (AI) could help the management of patients treated with mechanical ventilation in critical care practice. Current guidelines are based on data coming from the general population, without considering the individual patients' characteristics. With the use of AI for mechanical ventilation, critical care practice could be improved by offering personalized treatments, reducing complications, and assisting clinicians in decision-making to improve patient outcomes and reduce mortality rates. Despite AI in medicine has progressed in the last decade, little is known about its use in critical care and in ventilation management. In order to improve its everyday use, future research should be performed in intensive care settings. [ABSTRACT FROM AUTHOR]

Introduction: Invasive mechanical ventilation (IMV) is frequently used as a life-supporting device in Pediatric Intensive Care Units (PICU). To date, there are few studies evaluating the impact of prolonged mechanical ventilation (PMV) in children which is associated with high morbidity and mortality. We aimed to determine the incidence and factors associated with PMV in PICU at our institution. Methods: A retrospective review was performed of children aged 1 month to 18 years who were admitted to the PICU at Chiang Mai University Hospital, Thailand between January and December 2020. PMV was defined if the duration of IMV was ≥ 96 hours. Baseline characteristics and factors associated with PMV were analyzed by descriptive statistics, and univariable and multivariable logistic regression analysis, respectively. A p-value of < 0.05 was considered significant. Results: Ninety-two episodes of IMV were performed in 90 children. The median (IQR) age of the children was 22.8 (7.2–111.9) months (male 64.1%). Forty-six of 92 (50%) children received PMV and 32.6% of children with PMV required a tracheostomy. Following multivariable analysis, factors associated with PMV were age <2 years old (OR 2.86, 95% CI 1.04–7.84, p = 0.041), male gender (OR 3.21, 95% CI 1.15–8.94, p = 0.026), and multiple antibiotics administration during PICU admission (OR 7.83, 95% CI 1.87–32.78, p = 0.005), respectively. Conclusions: Pediatric PMV was notably common, with younger age, male gender, and multiple antibiotic use contributing to higher risk. Developing weaning protocols and strategies to reduce PMV duration is crucial. [ABSTRACT FROM AUTHOR]

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Objective: This study aimed to analyze the clinical characteristics and prognosis of patients with autoimmune encephalitis (PWAE) who experienced seizures during the acute phase. Methods: Clinical data were collected from 84 patients diagnosed with AE at the General Hospital of Ningxia Medical University between January 2015 and January 2023. Patients were divided into seizure and non-seizure groups. Clinical characteristics of both groups were compared, including differences between anti-NMDAR and anti-LGI1 encephalitis within the seizure group. Due to the limited sample size and to avoid overfitting, we focused on univariate logistic regression analysis to identify individual prognostic factors. Results: A total of 84 patients were enrolled, with 76.19% (64/84) in the seizure group and 23.81% (20/84) in the non-seizure group. The seizure group had a longer hospital stay (p = 0.013), higher rates of impaired consciousness (p = 0.001), and more frequent intensive care unit (ICU) admission (p = 0.011). They also had higher peripheral blood neutrophil-to-lymphocyte ratio (NLR), leukocyte count, and uric acid levels (p = 0.038, p = 0.006, p = 0.020), and were more likely to show slow-wave rhythms on electroencephalography (EEG) (p = 0.031). At 2-year follow-up, there was no significant difference in prognosis between the seizure and non-seizure groups (p = 0.653), with 35.94% (23/64) of the seizure group having a poor prognosis. Status epilepticus (SE), complications, endotracheal intubation, mRS score at discharge, APE2, and RITE2 scores increased the risk of poor prognosis (OR > 1), while intensive care and albumin reduced the risk (OR < 1). Conclusion: Seizures are common in the early stages of AE, with faciobrachial dystonic seizures (FBDS) characteristic of anti-LGI1 encephalitis and SE and super-refractory status epilepticus (Sup-RSE) frequently observed in anti-NMDAR encephalitis. Seizure semiology across AE subtypes lacks specificity, and no symptoms clearly distinguish immune-mediated from non-immune causes. While seizures are linked to AE severity, particularly in anti-NMDAR encephalitis, they do not appear to impact overall prognosis. SE, complications, endotracheal intubation, modified Rankin Scale (mRS) score at discharge, Antibody-Prevalence in Epilepsy and Encephalopathy (APE2) score, Response to Immunotherapy in Epilepsy and Encephalopathy (RITE2) score, intensive care, and albumin were identified as significant prognostic factors. [ABSTRACT FROM AUTHOR]

Background/aim: Benign tracheal stenosis (TS) is a potentially life-threatening condition caused by iatrogenic events resulting from endotracheal intubation and tracheostomy. The study aimed to determine the clinical characteristics, management, and long-term outcomes of patients with simple or complex post-intubation tracheal stenosis (PITS) who were admitted to the intensive care unit (ICU). Materials and methods: Retrospective analysis of patients admitted to the ICU between June 2016 and June 2022 and diagnosed with PITS were performed until June 2023. Results: 76 patients (mean age 54.9 ± 17.3%, 63.2% male, 61.8% complex stenosis) admitted to the ICU were analysed. The diagnosis of PITS was made by fiberoptic bronchoscopy (FOB) in 53.9% and computed tomography (CT) in 46.1%. The most common location of stenosis was the upper trachea area (57.9%, n = 44). The median stenosis length of the TS was 1.9 cm (median 2 cm for complex stenosis, 1 cm for simple stenosis, p < 0.001). Complex stenosis was associated with longer intubation time and multiple intubation history (p = 0.011, p = 0.028). At the same; complex stenosis was associated with prolonged and high stenosis percentage (p < 0.001). While dilatation and cryotherapy were sufficient for treatment in all patients with simple stenosis, the stent was applied to 34% patients with complex stenosis. Recurrence was higher in complex stenosis after bronchoscopic procedure (complex stenosis 95.7%, simple stenosis 17.2%). 19 (25%) patients required surgical operation, and all of these patients had complex stenosis (p < 0.001). Median follow-up was 33 months for simple stenosis and 34 months for complex stenosis. ICU length of stay (LOS) was longer in patients with complex stenosis. There was no statistically significant difference between TS classes in terms of ICU mortality (p = 0.466), 1-year mortality (p = 0.951), and mortality during follow-up (p = 0.608). Conclusion: PITS is a challenging situation in ICU patients. In patients with a preliminary diagnosis of PITS, bronchoscopy should be performed without delay, and it should be known that interventional bronchoscopy is not only a diagnostic tool but an effective strategy in treatment management after the diagnosis is finalised. The advantage of interventional bronchoscopy is that it alleviates symptoms that necessitate hospitalisation in the ICU and eliminates the need for ICU of patients. [ABSTRACT FROM AUTHOR]

Background: The most appropriate anti-inflammatory treatment for moderate COVID-19 pneumonia remains uncertain. We aimed to compare the effectiveness of a high-dose methylprednisolone versus a high-dose dexamethasone in hospitalized moderate COVID-19 pneumonia, regarding the WHO clinical progression scales, mortality, and the length of hospitalization. Methods: In this open-labeled randomized controlled trial, we enrolled patients with age > 18 years old who were diagnosed moderate COVID-19 pneumonia confirmed by real-time PCR, evidence of pneumonia by chest imaging and resting oxygen saturation between 90 and 94%. Patients were randomized at a 1:1 ratio to receive methylprednisolone 250 mg/day or dexamethasone 20 mg/day over the first three days. Then the patients in both groups received dexamethasone 20 mg/day on days 4–5, and 10 mg/day on days 6–10. Primary outcome was assessed by a 10-point WHO clinical progression scales ranging from uninfected (point 0) to death (point 10) on the fifth day of treatment. Secondary outcomes including 90-day mortality, length of hospitalization, rate of intensive care unit (ICU) transfer and complications were determined. Results: Of 98 eligible patients, the mean age was 76.0 ± 13.3 years. The median date of illness at the time of randomization was 3 days (interquartile range 2, 5). Baseline clinical characteristics and severity did not differ between groups. The WHO clinical progression scales were similar between methylprednisolone and dexamethasone group at 5 and 10 days of treatment [4.84, (95% confidence interval(CI), 4.35–5.33) vs. 4.76 (95% CI, 4.27–5.25), p = 0.821 and 4.32 (95% CI, 3.83–4.81) vs. 3.80 (95% CI, 3.31–4.29), p = 0.140, respectively)]. Both groups did not differ in-hospital mortality, length of hospitalization, and rate of ICU transfer. There were also no differences in steroid-related complications between groups until 90 days of follow-up. Conclusions: In patients with moderate COVID-19 pneumonia, initial anti-inflammatory treatment with 250 mg/day of methylprednisolone for three days does not yield better outcomes over high-dose dexamethasone. Trial registration: This study was registered at Thai Clinical Trials Registry on October 17, 2021, with the identifier TCTR20211017001. [ABSTRACT FROM AUTHOR]

Background: Many patients hospitalized for COVID-19 experience long-term health problems, but comprehensive longitudinal data up to 2 years remain limited. We aimed to (1) assess 2-year trajectories of health outcomes, including comparison between intensive care unit (ICU) treated and non-ICU-treated patients, and (2) identify risk factors for prominent health problems post-hospitalization for COVID-19. Methods: The CO-FLOW multicenter prospective cohort study followed adults hospitalized for COVID-19 at 3, 6, 12, and 24 months post-discharge. Measurements included patient-reported outcomes (a.o., recovery, symptoms, fatigue, mental health, sleep quality, return to work, health-related quality of life [HRQoL]), and objective cognitive and physical tests. Additionally, routine follow-up data were collected. Results: 650 patients (median age 60.0 [IQR 53.0–67.0] years; 449/650 [69%] male) surviving hospitalization for COVID-19 were included, of whom 273/650 (42%) received ICU treatment. Overall, outcomes improved over time. Nonetheless, 73% (322/443) of patients had not completely recovered from COVID-19, with memory problems (274/443; 55%), concentration problems (259/443; 52%), and dyspnea (251/493; 51%) among most frequently reported symptoms at 2 years. Moreover, 61% (259/427) had poor sleep quality, 51% (222/433) fatigue, 23% (102/438) cognitive failures, and 30% (65/216) did not fully return to work. Objective outcome measures showed generally good physical recovery. Most outcomes were comparable between ICU- and non-ICU-treated patients at 2 years. However, ICU-treated patients tended to show slower recovery in neurocognitive symptoms, mental health outcomes, and resuming work than non-ICU-treated patients, while showing more improvements in physical outcomes. Particularly, female sex and/or pre-existing pulmonary disease were major risk factors for poorer outcomes. Conclusions: 73% (322/443) of patients had not completely recovered from COVID-19 by 2 years. Despite good physical recovery, long-term neurocognitive complaints, dyspnea, fatigue, and impaired sleep quality persisted. ICU-treated patients showed slower recovery in neurocognitive and mental health outcomes and resumption of work. Tailoring long-term COVID-19 aftercare to individual residual needs is essential. Follow-up is required to monitor further recovery. Trial registration: NL8710, registration date 12-06-2020. [ABSTRACT FROM AUTHOR]

Introduction: Acute respiratory distress syndrome (ARDS) is characterized by diffuse lung injury. The impact of pre-existing chronic obstructive pulmonary disease (COPD) or emphysema on ARDS pathogenesis is not well characterized. Methods: Secondary analysis of ARDS patients enrolled in the Acute Lung Injury Registry and Biospecimen Repository at the University of Pittsburgh between June 2012 and September 2021. Patients were categorized into two mutually exclusive groups by the prevalence of COPD or emphysema at the time of ARDS diagnosis. The COPD/emphysema group comprised ARDS patients with radiological evidence of emphysema, chart diagnosis of COPD, or both. Demographics, lung mechanics, and clinical outcomes were obtained from the electronic medical record. Host-response biomarkers known to have validated associations with ARDS were previously measured in plasma and lower respiratory tract samples using a customized Luminex assay. Continuous and categorical variables were compared between groups with and without COPD/emphysema. Results: 217 patients with ARDS were included in the study, 57 (27%) had COPD/emphysema. Patients with COPD/emphysema were older (median 62 [interquartile range 55–69] versus 53 [41–64] years, p < 0.01), more likely to be male (62% vs. 44%, p = 0.02) and had a higher prevalence of congestive heart failure (25% vs. 4%, p < 0.01) compared to patients without COPD/emphysema. Baseline demographics, laboratory parameters, and mechanical ventilatory characteristics were otherwise similar between the two groups. No difference in 90-day mortality was observed between groups; however, patients with COPD/emphysema had shorter duration of intensive care unit (ICU) stay (median 10 [7–18] versus 16 [9–28] days, p = 0.04) and shorter duration of mechanical ventilation (median 7 [4–16] vs. 12 [6–20] days, p = 0.01). Host response biomarkers in serum and lower respiratory tract samples did not significantly differ between groups. Conclusion: ARDS patients with COPD or emphysema had similar respiratory mechanics, host response biomarker profiles, and mortality compared to those without COPD or emphysema but with a shorter median duration of mechanical ventilation and ICU length of stay. Future studies should address differences in clinical and biological responses by disease severity, and should investigate the impact of severity of COPD and emphysema on mechanical ventilation and targeted therapeutic strategies in ARDS. Clinical trial number: Not applicable [ABSTRACT FROM AUTHOR]

ABSTRACT Background/Objectives Methods Results Conclusions Miliaria pustulosa is a noninfectious, transient skin eruption of pustules overlying erythematous plaques secondary to obstruction of eccrine glands. There are very few case reports in the literature detailing miliaria pustulosa in neonates. When presenting in neonates, its similarity to life‐threatening infections may cause diagnostic confusion. By differentiating this condition from similar presentations, unnecessary treatments and tests in this population may be avoided.Retrospective review of the medical records of nine neonates presenting with a pustular eruption diagnosed as miliaria pustulosa. Patients were seen at a children's hospital in Chicago, IL, USA; cases were selected by investigator recall.In this case series, miliaria pustulosa presents in nine neonates as clusters of eruptive pustules with resolution or significant improvement noted after an average of 2.6 days (range 1–5 days). The average age was 4.6 days (range 1–10 days old) and the average gestational age was 34.7 weeks (range 26.3–40.1 weeks). All patients had pustular outbreaks in areas occluded by swaddling, clothes, or adhesive. Seven patients had geometric lesions that were underlying sites of intravenous (IV) site adhesive or electrocardiogram (EKG) leads.The consistent morphological features of this pustular eruption at sites of skin occlusion and the transient course in the setting of an otherwise well‐appearing infant are strongly suggestive of the diagnosis of miliaria pustulosa. It is important for clinicians to be familiar with this benign presentation and to differentiate it from other neonatal pustular eruptions to minimize invasive tests and treatments in this vulnerable population. [ABSTRACT FROM AUTHOR]

Introduction: Ludwig angina is a rare, rapidly spreading submaxillary, submandibular, and sublingual necrotizing life-threatening widespread cellulitis of the soft tissue on the floor of the mouth that can cause fatal complications because of airway obstruction. Currently, there are few published studies assessing the efficacy of superficial cervical plexus block for airway surgery and there is no agreement in the literature about airway management. The published recommendations differ and are based on the authors' own experiences and available resources. This report aimed to provide insight into critical patient management by performing regional anesthesia with fewer complications to the cardiovascular and respiratory systems. Case presentation: We report the case of a 70 year-old hypertensive Black Ethiopian woman with American Society of Anesthesiologist–Physical Status class III and hypertension, who was admitted to the hospital for treatment by her surgeon. The surgeon diagnosed her with Ludwig angina. After adequate physical examination and laboratory investigation, she arrived at the operation room for exploration and drainage of the abscess with a superficial cervical plexus block. She arrived safely at the adult intensive care unit for frequent suctioning. The block was effective until 6 h after the procedure with visual analogue scale (2/10), her vital signs remained stable throughout the postoperative period, and then the tracheostomy tube was removed by the surgeon after 10 days. The patient's hemodynamic status and breathing effort were satisfactory, and she was discharged 15 days later. Clinical discussion: Proper airway management is critical for the survival of patients diagnosed with Ludwig angina. According to recent studies, an increasing number of patients with Ludwig angina require intensive care unit admission for tracheal intubation and mechanical breathing. However, it is uncertain whether intensive care reduces the death rate in patients with Ludwig angina. Finally, it is suggested that studies with large sample sizes and strong levels of evidence be conducted to conclude the effectiveness of superficial cervical plexus block for airway emergency surgeries. Conclusion: Management of the airway in patients with Ludwig angina is challenging. Clinicians must take precautions and make sharp decisions on the basis of a variety of circumstances, including the availability of equipment at medical facilities, such as fiberoptic intubation equipment; the anesthetist's level of experience, such as performing superficial regional block and good mask ventilation; and the patient's medical status at the time of presentation. As a result, intervention needs to be quick so as to avoid airway obstruction and further complications. [ABSTRACT FROM AUTHOR]

ABSTRACT Background Objectives Design Methods Results Conclusions Implications for Clinical Practice Patient or Public Contribution Pressure injuries (PIs) impose a significant burden on patients in the intensive care unit (ICU) and the healthcare system. Assessing the risk of developing PIs is crucial for prevention. However, it is unclear whether all subscales of the Waterlow scale can be used to assess PIs risk in ICU.To assess whether all subscales of the Waterlow scale can predict PIs risk in ICU.Multicentre prospective study.A total of 18,503 patients from ICUs in 40 tertiary‐level hospitals in Gansu province of China were enrolled from April 2021 to August 2023. The incidence and characteristics of PIs were recorded. Univariate Cox regression analyses were performed for each subscale as a predictor of PIs development, followed by multivariate Cox regression with covariates for each subscale separately.Out of 17,720 patients included, the incidence of PIs was 1.1%. Multivariate analysis revealed skin type (HR: 1.468, 95% CI: 1.229, 1.758), sex (HR: 0.655, 95% CI: 0.472, 0.908), advanced age (HR: 1.263, 95% CI: 1.106, 1.442), continence (HR: 1.245, 95% CI: 1.052, 1.473), tissue malnutrition (HR: 1.070, 95% CI: 1.007, 1.136) and neurological deficit (HR: 1.153, 95% CI: 1.062, 1.251) were independently predictive of PIs development for all participants. Skin type (HR: 2.326, 95% CI: 1.153, 3.010) (HR: 2.217, 95% CI: 1.804, 2.573) independently predicted PIs occurrence for high‐risk and very high‐risk group, respectively, while sex (HR: 0.634, 95% CI: 0.431, 0.931) and age (HR: 1.269, 95% CI: 1.083, 1.487) predicted PIs development for very high‐risk group.This study found that not all subscales of the Waterlow scale are associated with the PIs development in patients in ICU, highlighting the importance of the skin type subscale in predicting PI risk across all patient groups.Nurses need to focus on patient's skin and related (moisture, pain and pressure) conditions and take measures to promote skin health and avoid the occurrence of PI.None. [ABSTRACT FROM AUTHOR]

Subjective Social Status (SSS) reflects one’s perceived rank within a given social structure and has been shown to be a unique correlate of physical and mental health. However, no research has been conducted to address populations of (recovering) critically ill patients. To shed light on the relationship between SSS and health in critically ill patients, we focus on survivors of acute respiratory distress syndrome (ARDS). A cohort study with N = 877 ARDS survivors was conducted in 61 intensive care units (ICUs) in Germany between 2014 and 2019. Health-related quality of life (HRQoL, Physical and Mental Component Scale: PCS, MCS of the SF-12) and SSS (MacArthur Scale) were assessed at 12, 24, and 36 months after discharge from ICU. Objective social status (Socioeconomic status [SES]) was assessed once at ICU baseline. Bivariate correlations between SSS and HRQoL (PCS and MCS) remain significant throughout the study period (r = .29 – .50, all p-values < .05). Subsequent hierarchical regression shows that SSS remains predictive for PCS and MCS even after controlling for SES (β = .335 – .486, all p values < .001). The results indicate the importance (and unique contribution) of the subjective localization within the status hierarchy for long-term HRQoL after critical illness. [ABSTRACT FROM AUTHOR]

Fever is common in the ICU, with infectious causes accounting for only half of febrile episodes. This case examines a young male who developed high‐grade fevers and pulmonary infiltrates unresponsive to broad‐spectrum antibiotics. Examination revealed hepatosplenomegaly, hypertriglyceridemia, anemia, and thrombocytopenia, suggestive of hemophagocytic lymphohistiocytosis (HLH). Meeting 5 of 8 HLH criteria, high‐dose steroids were administered, resulting in clinical improvement. HLH, with a high mortality risk, demands early recognition, complicated by nonspecific symptoms. This case highlights the rare manifestation of ARDS in HLH, adding diagnostic challenges in critical care settings. [ABSTRACT FROM AUTHOR]

Background: Suicide has become a first-order public health concern after the negative impact of COVID-19 on the general population's mental health. Several studies have analyzed the trends in suicide attempts (SA) before and after the onset of the pandemic, but few studies focus on the impact of the pandemic on medically serious suicide attempts (MSSA). Methods: Participants were 385 hospitalized individuals ≥ 16 years old who made MSSA identified retrospectively through a review of e-medical records between 2018 and 2022 ("pre-COVID-19" and "COVID" periods). The two groups were compared on sociodemographic and clinical variables using Chi-square or Exact Fisher's tests for categorical variables and a Mann-Whitney test for continuous variables. To study the variation in MSSA over time, MSSA were aggregated monthly. Joinpoint regression analyses were used to assess time trends. Results: A sample of 161 MSSA patients, 80 women and 81 men, were selected from 385 admissions after a suicide attempt (SA) in the four years (n = 160 pre-COVID period vs. n = 225 COVID period) (OR = 1.41; CI 95% = 1.0003–1.7223, p < 0.001). Sixty-eight patients with MSSA were admitted during the first period, and 93 during the COVID period (OR = 1.4 ; CI 95% = 1–1.9 ; p < 0.05). MSSA patients were more likely to be admitted to an intensive care unit during the COVID period than during the pre-COVID period (OR = 3.5; CI 95% = 1.7–6.9; p < 0.001). Conclusions: This study highlights the need for research on suicide risk during and after crisis periods, such as the COVID-19 pandemic. It provides valuable knowledge on the incidence of SA needing hospitalization, MSSA, and highly severe MSSA for four years before and after the pandemic onset. [ABSTRACT FROM AUTHOR]

Background: Fetal growth monitoring is important for twin pregnancies. However, there has been no clinically validated tool for monitoring fetal growth of twin pregnancies in China. This study aims to develop and validate a chorionicity-specific growth chart of ultrasound estimated fetal weight (EFW) for Chinese twin pregnancies. Methods: This retrospective cohort study included all twin pregnancies who delivered two live fetuses with gestational age ≥ 34 weeks without severe obstetric complications at a tertiary hospital from January 2007 to March 2021. The participants were divided into a development set (delivered in or before December 2017) and a validation set (delivered in or after January 2018). Chorionicity-specific growth charts were created using the generalized additive models for location, scale, and shape (GAMLSS) based on the development set. The fetuses from the validation set were classified into three groups based on the last EFW: small-for-gestational-age (SGA) indicated by both the newly established twin charts and the Hadlock singleton chart currently used for twin pregnancies in China, suspected SGA indicated by only the singleton chart, and no SGA indicated by either chart. The incidence of neonatal outcomes among the three groups was then compared accordingly, including intensive care unit (NICU) stay length, respiratory diseases, and neurological disorders. Results: The development set included 883 twin pregnancies and a total of 6374 EFW measurements between 16 and 38 weeks of gestation, and the validation set included 801 twin pregnancies and 7630 EFW measurements. In the development set, monochorionic diamniotic (MCDA) twins had a significantly lower EFW compared to dichorionic diamniotic (DCDA) twins beginning at 26 weeks, with the difference gradually increasing thereafter, supporting the establishment of chorionicity-specific growth charts. Of the 1,602 twin neonates in the validation set, 103 (6.4%) were classified into the SGA group, 164 (10.2%) into the suspected SGA group, and 1335 (83.3%) into the no SGA group. The incidence of respiratory diseases and neurological disorders was comparable between the suspected SGA group and the no SGA group, but apparently higher in the SGA group. Meanwhile, NICU stay lengths were consistently longer for twins in the SGA group compared to the no SGA group (difference: 0.57, 95% CI: 0.31–0.83), with no significant differences observed between the suspected SGA and no SGA groups. Conclusions: The fetal growth trajectories differed by chorionicity, with a lower EFW for MCDA twins beginning at 26 weeks. The establishment of chorionicity-specific growth chart could reduce overdiagnosis of SGA and improve fetal growth monitoring of twin pregnancies. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to examine the reliability and validity of the Turkish version of the Nursing Activities Score. Methods: To validate the Turkish version of the Nursing Activities Score, a sample comprising 30 adult intensive care patients and 30 nurses was employed. After a pilot study, the internal consistency, Cronbach's alpha coefficient, was found to be p = 0.718. Following the significant internal consistency obtained in the pilot study, the correlation between Nursing Activities Score internal consistency and Critical Nursing Situation Index scores was examined in 150 adult intensive care patients and 150 nurses. Results: The assessment of inter-rater reliability showed a high level of agreement (99%) and an average Kappa index of 0.598 (p < 0.001). Concurrent validity was demonstrated through a statistically significant correlation between Nursing Activities Score and the Critical Nursing Situation Index (r = 0.71, p < 0.001) and multivariate regression analysis (R2 = 83%, p < 0.001). The validity is supported by the statistically significant relationship between Nursing Activities Score and Critical Nursing Situation Index. Conclusion: These results demonstrate that Nursing Activities Score is a valid and reliable tool for measuring nursing workload in Turkish intensive care units. Trial registration: Samsun University Samsun Training and Research Hospital, following ethics committee approval (Samsun University clinical research ethics committee (KAEK) 202312/2) and Clinical Trials (NCT04928040) registration. [ABSTRACT FROM AUTHOR]

Background: The outcomes of recent advancements in pediatric tracheostomy remain unclear. This study was conducted to identify the trends in pediatric tracheostomy in Taiwan. Methods: This population-based survey was conducted using data from Taiwan's National Health Insurance Research Database. We identified inpatients younger than 18 years who had undergone tracheostomy in Taiwan between 2000 and 2019. The study period was divided into subperiods (2000-2004, 2005-2009, 2010-2014, and 2015-2019). We analyzed patient characteristics and trends related to age, gender, hospital level, surgical indications, hospital stay duration, and mortality rates. The trends were analyzed for all pediatric patients (age <18 years) and infants (age <1 year). Results: This study included 2465 pediatric patients (mean age: 8.7 ± 6.9 years; boys: 64%). The incidence of pediatric tracheostomy decreased from 3.3 events per 100,000 individuals in 2000 to 2.1 events per 100,000 individuals in 2019 (P for trend <.001). The proportion of infants who received tracheostomy increased from 22.8% in 2000-2004 to 32.5% in 2015-2019 (P for trend =.06). The proportion of pediatric patients who received tracheostomy at medical centers increased and those at regional hospitals or district hospitals decreased (74.7%-81.0% vs 25.3%-19.0%, P for trend =.003). The proportion of pediatric patients with trauma or brain injury as a surgical indication decreased from 36.6% to 28.7% (P for trend =.001). The duration of intensive care unit (ICU) stays increased from 30 days in 2000-2004 to 50 days in 2015-2019 (P for trend <.001), and that of hospital stay increased from 58 days in 2000-2004 to 71 days in 2015-2019 (P for trend =.001). The 5-year mortality rate slightly decreased from 38.0% in 2000-2004 to 33.3% in 2005-2009 and 31.0% in 2010-2014 (P for trend =.006). Conclusions: Our findings revealed that during the study period, the number of pediatric patients receiving tracheostomy decreased, but the proportion of infants receiving tracheostomy increased. The trends in pediatric tracheostomy indicated extended ICU stay, prolonged hospital stay, and reduced 5-year mortality rates. [ABSTRACT FROM AUTHOR]

AbstractBackgroundMethodsResultsConclusionUrinary tract infections (UTIs) are prevalent among patients carrying indwelling catheters in the intensive care unit (ICU). This study investigates antibiotic use and bacterial colonisation among ICU patients during the third wave of the COVID-19 pandemic, building on our prior discovery of increased Enterococcus colonisation associated with increased cephalosporin use in early COVID-19.Longitudinal urine samples from COVID-19 patients (n = 109) with transurethral catheterisation were analysed for bacterial prevalence, further identified via MALDI-TOF. Microbiological results were combined with clinical data obtained daily, assessed and compared with COVID-19 waves 1 and 2.Patients in wave 3 exhibited improved outcomes compared to those in waves 1 and 2, alongside a decrease in antibiotic use. Staphylococcus emerged as the primary bacterium and early colonizer of the urinary tract, potentially due to the absence of antibiotic treatment. Our results imply that length of stay (LOS) correlates solely with enteric pathogens and that antibiotic treatment correlates with colonisation by certain uropathogens, whereas the absence of antimicrobial therapy is associated with rapid colonisation of skin flora. Polymicrobial colonisation was common, predominantly involving Gram-positive bacteria.Our findings underscore the complexity of bacteriuria in ICU patients, advocating for targeted surveillance and tailored antibiotic approaches to mitigate UTI risk. Insights into antibiotic use and bacterial colonisation are vital for optimising stewardship practices, combating antimicrobial resistance, and enhancing ICU patient outcomes. [ABSTRACT FROM AUTHOR]