To explore women's participation in decision-making related to the type of anaesthesia for elective caesarean section. The exploratory, descriptive qualitative study was conducted from June to August 2021 and comprised women aged at least 18 years who were either planned for elective caesarean section or had undergone elective caesarean section at a tertiary care hospital in Islamabad, Pakistan, and a secondary care hospital in the mountainous northern areas of the country. was triangulated via semi-structured interviews and observations. Data was subjected to manual content analysis, and codes were assigned based on manifest and latent information. The codes were merged to form categories, and a theme was extracted after repeated reflection on the categories. Of the 20 women with age ranging 25-38 years, 11(55%) were from the secondary care hospital, and 9(45%) were from the tertiary care hospitals. Overall, 11(55%) women received general anaesthesia and 9(45%) received spinal anaesthesia. Data saturation was achieved in the 14th interview 14 (70%) and the remaining 6(30%) subjects were observed by the researchers. Content analysis led to four categories: initiation of discussion about anaesthesia, quality of discussion about anaesthesia, opportunity for patients' input in the decision, and factors influencing the decision. The categories led to the generation of an overarching theme: ensure the norms; follow the commands. The decision regarding the choice of anaesthesia for caesarean sections was usually in line with the hospitals' unwritten standards, which were either aligned with evidence-based medical practice, or the availability and competence of anaesthesiologists. Women were usually the recipients of information by the anaesthesiologists.
To investigate the effects of different ventilatory approaches during the recovery phase of anaesthesia on the incidence of atelectasis. The prospective cohort study was conducted from August to November 2022 at Dokuz Eylul University Hospital, Izmir, Turkiye, and comprised patients aged at least 18 years with an American Society of Anaesthesiologists physical status classification of I-III who were undergoing elective ophthalmic surgery, extremity surgeries, or septorhinoplasty procedures under general anaesthesia with endotracheal intubation for a duration of 1-3 hours. The patients were divided into pressure support ventilation group A and manual ventilation group B. Lung ultrasonography was performed preoperatively and postoperatively using a lung transthoracic ultrasound score system ranging 0-36. Degree of atelectasis in each lung region was rated on a 0-3 scale, and a total score was computed for every patient. Patients with a total score 0 were classified as having no atelectasis, while those with a score of 1 or higher were classified as having atelectasis. Data was analysed using SPSS 25. Of the 2878 patients, 139(50%) were in group A; 72(51.8%) males and 67(48.2%) females with overall mean age 45.4±19.1 years. The remaining 139(50%) were in group B; 71(51.1%) males and 68(48.9%) females with overall mean age 49.7±18.6 years (p>0.05). The total postoperative lung ultrasonography median values were 1 (interquartile range: 0-3) in group A and 2(interquartile range: 0-4) in group B (p=0.041). Atelectasis was present in 106(76%) patients in group B compared to 84(60%) patients in group A (p=0.005). In patients who received pressure support ventilation, a lower incidence of postoperative atelectasis was observed, suggesting that pressure support ventilation may be a more effective ventilation method in the postoperative period. NCT06358027.
Long COVID-19 affects approximately 10-30% of individuals who are infected with SARS-CoV-2 and is associated with persistent functional impairment and reduced quality of life. The heterogeneous, multisystemic nature and nonspecific symptomatology of long COVID-19 makes its treatment challenging. This scoping review evaluates existing evidence on sympathetic and parasympathetic ganglion blocks as potential interventions for patients suffering from long COVID-19. Our primary objective was to assess the effectiveness of sympathetic and parasympathetic ganglion blocks in treating patients with long COVID-19 by identifying the most commonly reported symptoms, symptom response to different block regimens, and any adverse effects associated with these interventions. A scoping review. Outpatient clinics where patients received sympathetic blocks or parasympathetic blocks. A comprehensive search was conducted across PubMed, Embase, Cochrane CENTRAL, Web of Science, Google Scholar, and ClinicalTrials.gov using MeSH and free-text terms related to "long COVID-19," "post-COVID-19 syndrome," and "sympathetic ganglion blocks" and "parasympathetic blocks." Only English-language articles were included. Pre-print repositories and reference lists were also manually screened. A total of 22 articles covering 505 patients were included in this review. The most frequently studied symptoms were olfactory dysfunction, fatigue, headache, and cognitive disturbances. The most commonly utilized intervention was the stellate ganglion block. The available evidence suggests that the stellate ganglion block could be an effective treatment for dysautonomia symptoms and cognitive dysfunction related to long COVID-19. Sphenopalatine ganglion block may be an effective option to treat headaches in long COVID-19 patients who are refractory to other treatments. The significant existing variations in treatment regimens precluded our ability to do a quantitative analysis. Reporting bias from case reports and small observational studies should also be considered. Stellate ganglion blocks may offer therapeutic benefit for the dysautonomia and cognitive dysfunction associated with long COVID-19. Sphenopalatine ganglion blocks have shown promise in managing refractory headache symptoms in this population. Further well-designed, placebo-controlled randomized studies that employ validated outcome measures are required to establish the efficacy of sympathetic ganglion blocks in the treatment of long COVID-19.
A 62-year-old male presented to the dermatology department with a primary complaint of an achromatic tumorous lesion protruding above the surrounding skin, with central atrophy, irregular borders, and visible telangiectasias, located on the nasal distal third, slightly toward the left nasal dorsum. Based on the clinical presentation, basal cell carcinoma was suspected and surgical excision under local anesthesia was recommended. [...].
Equivocal data exist on whether noradrenaline during resuscitation from circulatory shock affects tissue mitochondrial respiration. Therefore, we examined the relation between myocardial mitochondrial respiration and plasma noradrenaline concentrations during continuous i.v. noradrenaline. After anesthesia and (neuro)surgical instrumentation, pigs underwent two hours of subdural blood injection and subsequent systemic blood removal, followed by fluid resuscitation, re-transfusion of shed blood, and noradrenaline to maintain cerebral perfusion pressure at pre-shock levels. Before, immediately after the challenge, and after 48 h of resuscitation, we measured whole blood superoxide anion levels (electron spin resonance) and DNA strand breaks ("tail moment" in the comet assay), and plasma noradrenaline (HPLC/tandem mass-spectrometry), NOx (chemoluminescence), isoprostane and troponin (ELISA) concentrations. Immediate post mortem myocardial samples were analyzed for mitochondrial respiration (high-resolution respirometry for Complex I/II activity, oxidative phosphorylation, and maximal uncoupled electron transfer capacity) as well as β1-/β2-adrenergic receptor and mitochondrial complex I/II expression, and nitrotyrosine formation (immunohistochemistry). At 48 h of resuscitation, plasma noradrenaline concentrations were 200-fold those at baseline, while NOx levels had doubled. Myocardial mitochondrial respiration was unrelated to noradrenaline, NOx, or nitrotyrosine, but directly related to both the β1- and β2-adrenoceptor expression (oxidative phosphorylation: r = 0.466, p = 0.059 and r = 0.750, p = 0.0005, respectively; maximal uncoupled electron transfer capacity: r = 0.514, p = 0.035 and r = 0.772, p = 0.0003, respectively). Oxidative phosphorylation was inversely related to the plasma troponin-I levels (r = -0.479, p = 0.060). While plasma NOx levels correlated with plasma noradrenaline levels (r = 0.519, p = 0.033), whole blood superoxide anion levels and cardiac nitrotyrosine formation did not. In a long-term, resuscitated porcine model of acute subdural hematoma and hemorrhage, plasma NOx levels correlated with noradrenaline plasma levels, whereas mitochondrial respiration and other markers of radical formation or oxidative/nitrosative stress were unrelated to noradrenaline concentrations. β-adrenergic receptor expression was also unrelated to noradrenaline, while mitochondrial respiration was directly related to both the β1- and β2-adrenoceptor expression. Our results suggest that the impaired mitochondrial respiration reported during septic shock for skeletal muscle may be absent in the heart during continuous i.v. noradrenaline for resuscitation from trauma-and-hemorrhage. Nevertheless, cardiac tissue injury is associated with reduced mitochondrial respiration.
Evidence is lacking to appraise whether radial access should be preferred to femoral access for coronary angiography (CAG) in critically ill patients. Patients admitted to the medical intensive care unit (ICU) of a university hospital over a 5-year period and requiring CAG immediately before or during the ICU stay were retrospectively included. The average treatment effect of the arterial route used for CAG was assessed through a win-ratio methodology with propensity score (PS)-based inverse probability of treatment weighting (IPTW). The primary endpoint was a hierarchical composite outcome of (i) all-cause death, (ii) resuscitated cardiac arrest, (iii) stroke, (iv) myocardial infarction, (v) acute limb ischemia and/or need for vascular surgery on CAG access site and (vi) Bleeding Academic Research Consortium (BARC) type 3 major bleeding, all assessed at day 28. The relationship between access site and the likelihood of all-cause death at day 28 was investigated with a Cox proportional hazard model stratified on the occurrence of cardiac arrest before CAG and adjusted through PS-based IPTW. Among the 235 included patients (116 with femoral access and 119 with radial access), 145 (61.7%) were admitted following cardiac arrest and 116 (49.4%) presented with cardiogenic shock at the time of CAG. The primary composite endpoint occurred in 63.4% of patients with femoral access and 47.7% of patients with radial access in IPT-weighted populations (absolute risk difference 15.6%, 95% confidence interval [CI] 1.4% to 29.8%, P = 0.03; win ratio for femoral versus radial access 0.62, 95% CI 0.40 to 0.98, P = 0.04). Access site complications were more frequent in patients with femoral access while major bleedings were similarly observed in both groups. Femoral access was not associated with day-28 mortality (adjusted hazard ratio 1.43, 95% CI 0.90 to 2.26, P = 0.13). Percutaneous coronary revascularisation and implantation of veno-arterial extra-corporeal membrane oxygenation, when required, were not hastened with femoral access. In this study, the use of a femoral rather than radial approach for CAG in critically ill patients was associated with a higher incidence of access site complications but did not correlate with the hazard of major bleeding or all-cause death at day 28.
Routine postoperative oxygen administration in the general ward is widely practiced despite limited evidence of benefit in low-risk surgical patients and increasing concerns regarding delayed detection of hypoventilation and unnecessary hyperoxia. Nasal high flow (NHF) therapy can reduce respiratory effort even without supplemental oxygen, but its feasibility and safety in the general ward during the acute postoperative period remain uncertain. This randomized feasibility study aimed to evaluate the feasibility, safety, and protocol adherence of oxygen-free NHF therapy in the general ward following oral surgery under general anesthesia, and to obtain preliminary physiological data to inform the design of a future confirmatory randomized controlled trial. Adult patients undergoing elective oral surgery under general anesthesia were randomized (1:1:1) to receive NHF with humidified room air at 40 L/min, conventional face mask oxygen at 5 L/min, or no respiratory support during the first 150 min in the general ward. Primary outcomes were feasibility-related parameters, including recruitment and protocol completion rates, tolerance of NHF therapy, need for rescue oxygen, and completeness of continuous physiological monitoring. Safety outcomes included the incidence of hypoxemia and clinically marked hypercapnia. Physiological outcomes included respiratory rate, transcutaneous oxygen (tcpO₂) and carbon dioxide (tcpCO₂) partial pressures, and oxygen saturation (SpO₂). All 48 enrolled patients completed the study protocol, demonstrating high feasibility with excellent recruitment, protocol adherence, and data completeness. NHF therapy was well tolerated, and no serious adverse respiratory events were observed. The incidence of hypoxemia and hypercapnia was comparable across the groups. Exploratory analyses showed a lower respiratory rate in the NHF group (NHF: 11.1 ± 2.8 min-1; control: 14.7 ± 2.7 min-1; face mask O2: 13.9 ± 3.0 min-1) without evidence of carbon dioxide retention. In contrast, face mask oxygen therapy frequently resulted in supraphysiological oxygenation, while maintaining comparable tcpCO₂ levels (NHF: 55.0 ± 15.9 mmHg; control: 52.2 ± 10.8 mmHg; face mask: 55.4 ± 10.0 mmHg). NHF without supplemental oxygen therapy was safe, and well tolerated as postoperative respiratory management in the general ward. The study addressed key feasibility concerns and provides essential data to support the design of a future adequately powered randomized controlled trial evaluating the clinical effectiveness of oxygen-free NHF. Trial registration: The study was registered as jRCTs072200018 on June.23, 2020 on the site of Japan Registry of Clinical Trials (jRCT). URL: https://jrct.mhlw.go.jp/latest-detail/jRCTs072200018 The trial started on July 1, 2020 and is currently recruiting. The date of enrollment of the first research participant was March 27, 2023.
Dexmedetomidine has been used as an adjuvant to minimize the adverse effects associated with opioids, either in the form of intravenous injection or intravenous infusion. The present study aimed to compare the efficacy of dexmedetomidine when administered via intravenous infusion and intravenous bolus injection. A comparative observational study was conducted among 1000 participants aged 35-65 years with American Society of Anesthesiologists physical status I/II, scheduled to undergo elective gynecological surgeries. Participants were divided into Group D (received a loading dose of bolus 0.5 μg/kg, followed by 0.3 μg/kg/h intravenous infusion of dexmedetomidine) and Group C (control group) 15 min before the induction of anesthesia. Hemodynamic variables, recovery time, rescue analgesia, pain scores, and any adverse events were recorded. Participants in Group D had lower hemodynamic parameters (after 1 h till the end of surgery) (P < 0.05). Participants in Group D took fewer rescue analgesics compared to Group C (P = 0.001), and recovery time was prolonged in Group D (P = 0.001). Pain scores were lower in Group D compared to Group C (P = 0.001). A loading dose of intravenous bolus followed by intravenous infusion of dexmedetomidine is a valuable adjunct in the perioperative management of such patients, offering potential benefits in enhancing recovery and reducing the need for postsurgical analgesia. Résumé Contexte:La dexmédétomidine a été utilisée comme adjuvant pour minimiser les effets indésirables associés aux opioïdes, par voie intraveineuse, ou par perfusion intraveineuse.Objectif:La présente étude visait à comparer l’efficacité de la dexmédétomidine administrée par perfusion intraveineuse et par injection intraveineuse en bolus. Matériel et méthodes: Une étude observationnelle comparative a été menée auprès de 1 000 participantes âgées de 35 à 65 ans, classées ASA I ou II, devant subir une intervention chirurgicale gynécologique programmée. Les participantes ont été réparties en deux groupes : le groupe D (ayant reçu une dose de charge de 0,5 µg/kg en bolus, suivie d’une perfusion intraveineuse de 0,3 µg/kg/h de dexmédétomidine) et le groupe C (groupe témoin), 15 minutes avant l’induction de l’anesthésie. Les variables hémodynamiques, le délai de réveil, le recours à l’analgésie de secours, les scores de douleur et tout événement indésirable ont été enregistrés.Résultats:Les participants du groupe D présentaient des paramètres hémodynamiques plus faibles (après 1 h jusqu’à la fin de l’intervention) (P < 0,05). Les participants du groupe D ont eu recours à moins d’analgésiques de secours que ceux du groupe C (p = 0,001), et le temps de récupération a été prolongé dans le groupe D (P = 0,001). Les scores de douleur étaient plus faibles dans le groupe D que dans le groupe C (P = 0,001).Conclusion:Une dose de charge de dexmédétomidine administrée par bolus intraveineux, suivie d’une perfusion intraveineuse, constitue un complément précieux à la prise en charge périopératoire de ces patients, offrant des avantages potentiels en termes d’amélioration de la récupération et de réduction du besoin d’analgésie postopératoire.
To develop and validate a clinical prediction model for intrapartum conversion to cesarean section in primiparous women receiving epidural labor analgesia. This retrospective cohort study included 1020 primiparous women who received epidural labor analgesia at a tertiary hospital in Wuxi, China. The model was developed to estimate cesarean conversion risk within this specific clinical cohort. Participants who delivered between March and December 2023 comprised the training cohort, whereas those who delivered between January and March 2024 comprised the validation cohort. Maternal, fetal, and intrapartum variables were extracted from electronic medical records, anesthesia records, and intrapartum fetal monitoring systems. A multivariable logistic regression model was developed to predict conversion to cesarean section, and a nomogram was constructed based on the final model. Model discrimination and calibration were assessed using the area under the receiver operating characteristic curve (AUC), the Hosmer-Lemeshow test, and calibration plots. Clinical utility was evaluated using decision curve analysis. The rate of conversion to cesarean section was 15.9% in the training cohort and 15.3% in the validation cohort. Six variables were identified as independent predictors of cesarean conversion: maternal age, intrapartum temperature, amniotic fluid characteristics, fetal heart rate status, use of oxytocin, and rupture of membranes during the first stage of labor. The prediction model showed good discrimination, with an AUC of 0.810 (sensitivity 0.822, specificity 0.606) in the training cohort. In the validation cohort, the AUC was 0.763 (sensitivity 0.786, specificity 0.592), indicating consistent predictive performance. This prediction model provides reliable risk estimation for conversion to cesarean section within a specific cohort of primiparous women receiving epidural labor analgesia. It may support early intrapartum risk stratification and individualized clinical decision-making. Further multicenter studies are warranted to assess its generalizability.
Inadvertent Perioperative Hypothermia (IPH) remains a common clinical problem. This study aimed to evaluate the efficacy of a multimodal temperature management strategy versus passive insulation in reducing the incidence of IPH among patients undergoing general anesthesia. This was a single-center, randomized, assessor-blinded randomized trial conducted at our hospital from November to December 2025. This study enrolled 206 patients scheduled for 4-8 h surgeries. They were randomly assigned to either a multimodal group (preoperative warming, forced-air warming blanket, fluid warming, increased ambient temperature, pharmacological intervention) or a control group (passive insulation with cotton quilts). Core body temperature was monitored at multiple perioperative time points. The primary outcome was the incidence of intraoperative hypothermia (core temperature < 36 °C). Secondary outcomes included inflammatory markers, blood gas parameters, fluid balance, pain scores, postoperative complications, and hospital length of stay. Compared with the control group, the multimodal group had a significantly lower incidence of intraoperative hypothermia starting at 90 min after surgery initiation (T5: control 60.6% vs. multimodal 48.0%; adjusted OR 0.37, 95% CI 0.15-0.93) and continuing to the end of surgery (T11: control 69.2% vs. multimodal 27.5%; adjusted OR 0.08, 95% CI 0.03-0.23). The multimodal intervention also reduced the incidence of hypothermia at operating room discharge (28% vs. 72%; adjusted OR 0.12, 95% CI 0.06-0.24) and suggest a potential reduction in the risk of postoperative cardiac adverse events (0% vs. 3.85%; P = 0.045). The multimodal group showed a greater increase in inflammatory markers (TNF-α, NLR, PLR), less pain at 48 h postoperatively, and a smaller reduction in pH. This multimodal temperature management bundle significantly lowers the incidence of perioperative hypothermia in patients undergoing prolonged surgery under general anesthesia, with benefits starting at 90 min and strengthening over time. It stabilizes metabolic parameters and may reduce cardiac complications and pain at 48 h postoperatively. https://www.chictr.org.cnChiCTR2500112554.Registered17/11/2025, first recruitment 20/11/2025.
This study aimed to evaluate the advantages of using double fluoroscopy during closed reduction and internal fixation of femoral neck fractures. In this prospective randomized study, 42 patients with femoral neck fractures treated between January 2021 and Sep-tember 2022 were included. Patients were randomly assigned to one of two groups: double fluoroscopy (Group A, n=20) or single fluoroscopy (Group B, n=22). The groups were compared in terms of preparation time, operative time, preparatory radiation time, and intraoperative radiation time. Baseline characteristics were comparable between the groups. There were no significant differences in age, sex, fracture side, fracture classification (Garden and Pauwels), mechanism of injury, anesthesia method, time to surgery, or duration of follow-up. The mean operative times were 73.1±7.25 minutes and 85.59±9.94 minutes for the double and single fluoroscopy groups, respectively (p<0.001). Total radiation times were 92.2±8.4 seconds and 113.27±18.1 seconds, respectively (p<0.001). Both operative and radiation times were significantly shorter in the double C-arm fluoroscopy group compared to the single C-arm fluoroscopy group. The use of a double fluoroscopy technique was associated with a significant reduction in operative time and radiation exposure overall in patients.
The dopamine D2 receptor (DRD2) is a key therapeutic target for several neuropsychiatric disorders, driving the need for new ligands with improved safety and efficacy. To find possible DRD2 inhibitors, we developed an integrated in silico workflow in this study that combines drug-likeness filtering, machine learning-based quantitative structure-activity relationship (ML-QSAR) modelling, and structure-based virtual screening. A standardized dataset of 1,128 DRD2 ligands with experimental inhibition constants was assembled, using pKi50 as the activity metric. Regression-based ML-QSAR models were constructed using the PubChem database and Substructure fingerprints. Random Forest techniques demonstrated the best prediction performance and robustness among these models. Crucial DRD2-binding motifs included aromatic systems, heterocycles, alkyl-aryl ethers, and halogenated groups. Strong agreement between predicted and experimental pKi50 values for FDA-approved antipsychotic medications further confirmed the validity of the model. A CNS-targeted chemical library was subjected to virtual screening, and the lead compounds were evaluated using molecular docking against the crystal structure of the dopamine D2 receptor (DRD2). VS012-7128 demonstrated strong binding affinities and formed essential interactions inside the receptor binding pocket in the molecular dynamics simulation. The study documented the effectiveness and reliability of the employed computational approach for identifying potential DRD2 ligands.
Tricuspid regurgitation and pulmonary artery systolic pressure may contribute to post-operative morbidity and mortality in liver transplantation. Previous studies suggest that a high Model for End-Stage Liver Disease score may influence the relationship between tricuspid regurgitation and post-operative mortality. Adult patients undergoing liver transplantation workup between 2010 and 2023 were included in this retrospective observational cohort study. Patients with significant portopulmonary hypertension were excluded. Transthoracic echocardiograms were completed pre-transplant and patients were followed up for one year post-operatively. 1031 patients (median MELD score 17, IQR 12-23) underwent transthoracic echocardiography for liver transplantation workup, of whom 708 underwent successful transplantation. Mild or greater tricuspid regurgitation did not predict 1-year mortality in the overall population (HR 1.79 (95% CI 0.78-4.11), p=0.19). Among patients with MELD scores ≥20, mild or greater tricuspid regurgitation was a significant predictor of 1-year mortality (7 (12.7%) vs. 9 (3.8%), p=0.01) (HR 3.46 (1.30-10.32), p=0.02). Tricuspid regurgitation in patients with high MELD scores was associated with a trend towards an increased risk of 30-day major adverse cardiovascular events (9 (16.4)% vs. 46 (8.1%), p=0.06), driven predominantly by rates of post-operative heart failure (12.7% vs. 3.8%, HR 3.66 (95%CI 1.30-10.32), p=0.01). Elevated pulmonary artery systolic pressure was associated with prolonged hospital stay (30 d (14-46) vs. 15 d (11-29), p=0.01). Our study confirms that mild or greater tricuspid regurgitation is a significant predictor of 1-year mortality in patients with high MELD scores undergoing liver transplantation. Tricuspid regurgitation severity should be considered during pre-liver transplantation risk stratification.
Artificial intelligence offers great opportunities in critical care, particularly when a vast amount of continuously acquired physiological data is incorporated. High-quality, reliably labelled data are paramount for developing and training artificial intelligence methods. However, routinely recorded data in critical care are often noisy, and the sheer volume of high-resolution data is challenging to manage. Generalizable solutions for these problems are lacking, restricting progress. To address these barriers, we developed Vitabel, an open-source Python framework for post hoc loading, visualizing, aligning, and annotating medical time series. The framework provides sensible defaults and interactive components for efficient use in preconfigured workflows, while remaining flexible and extendable for custom analysis and annotation pipelines. It integrates seamlessly into Jupyter Notebooks, providing an interactive, customizable interface for visual interaction with the data. In this publication, we demonstrate its utility across three use cases. The code and exemplary data are provided as browser-based demos. Vitabel is freely available and published under the MIT license accompanying this publication.
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United Kingdom National Institute for Health and Care Excellence (NICE) guidelines for evaluation of sepsis risk remain to be validated. This study aims to model the impact of the updated guidelines in patients identified as having a risk of sepsis based on the original guidelines. A single centre cohort study, between 2019 and 2022. Adult inpatients at risk of sepsis defined by red / amber flags in the original guideline were included. NICE criteria, based upon aggregate National Early Warning Score (NEWS2) and additional risk-factors (NEWS2 single parameter score three, lactate ≥2mmol/l, skin changes, acute kidney injury or deteriorating trajectory) were applied to this cohort to derive a revised risk classification. The primary outcome was the net reclassification index (NRI). Secondary outcomes were the association with a composite of critical care admission or death in hospital and the association with ICD-10 sepsis / Sepsis-3 status. 1303 hospital inpatients were included. Between red flag sepsis and NICE High-risk classification, there was agreement in 57.6%. The NICE model decreased the risk-classification in 471 (42.4%), of whom 216 experienced the composite outcome. The event RI deteriorated (-0.321), whilst the non-event RI improved (0.355). NICE High-risk had a similar C-statistic (0.57(0.55,0.60) vs. 0.56(0.54,0.58)) but with lower sensitivity (59.1% vs. 91.2%), higher specificity (55.1% vs. 20.2%) and PPV (55.9% vs. 52.1%) as compared to red flags. NICE High-risk had a greater C-statistic for association with Sepsis-3 status (0.66 (0.63, 0.69) vs. 0.55 (0.54, 0.57)). As implemented in this study, NICE criteria decreased the number of patients in a high-risk sepsis category, compared to a model using red flag criteria. These criteria decreased sensitivity and increased specificity for the outcome of critical care admission or death, whilst strengthening the association with Sepsis-3 criteria. Limited predictive performance advocates for clinically-led sepsis assessment.
Timely identification of acute stroke during medical emergency calls is critical for optimizing patient outcomes. We aimed to (i) characterize the prehospital trajectories of patients with stroke and (ii) explore the ability of an artificial intelligence (AI) model developed within the Artificial Intelligence Support in Medical Emergency Calls project to support decision-making at Emergency Medical Communication Centres (EMCCs). We conducted a retrospective analysis using data from 1,164 patients diagnosed with stroke from an EMCC (2018-2019), focusing on those primarily assessed by EMCC operators. We categorized patients into optimal and nonoptimal trajectory groups and applied logistic regression to explore the factors associated with an optimal trajectory. An AI model was trained using a dataset of 2,980 emergency calls (2019 and 2022), integrating transcribed audio logs and structured clinical data. The model was evaluated on the full dataset and subgroups that were incorrectly assessed by the EMCC. Aphasia/dysarthria was the only factor associated with optimal trajectories. The AI model achieved a sensitivity of 81.0%, specificity of 79.6%, and F1-score of 64.7%. The subgroup analysis included 14 false-negative and 41 false-positive cases. The model correctly predicted stroke in 9 of 14 false-negative cases and ruled out stroke in 9 of 41 false-positive cases. This explorative evaluation indicates that a multimodal AI pipeline combining audio and structured clinical data may show potential to support decision making in medical emergency calls. Internal results are promising, but studies on larger and external datasets are needed to validate these findings.
Transcatheter aortic valve implantation (TAVI) is increasingly performed under monitored anesthesia care (MAC); however, its use in patients with morbid obesity and obstructive sleep apnea (OSA) remains challenging because of the risk of hypoventilation and airway compromise. Prophylactic planned intraoperative non-invasive ventilation may offer a strategy to safely extend MAC to this high-risk population, but evidence in this setting remains scarce. We report a case of transfemoral TAVI successfully performed under MAC in a 67-year-old morbidly obese patient with severe OSA using bi-level non-invasive positive pressure ventilation (NIPPV), dexmedetomidine-based sedation, and regional analgesia. NIPPV was applied perioperatively to support spontaneous ventilation and optimize oxygenation, allowing the completion of the procedure without airway intervention or conversion to general anesthesia. The patient had an uneventful recovery and was discharged on the fourth postoperative day. This case demonstrates that prophylactic bilevel non-invasive positive pressure ventilation (NIPPV) can facilitate the safe use of monitored anesthesia care during TAVI in selected high-risk patients, supporting a physiology-driven strategy to maintain spontaneous ventilation while avoiding general anesthesia.
Since the discovery of the mammalian lanthionine synthetase C-like (LanCL) proteins, there has been considerable interest in identifying their functions. Using LAT8881, a novel peptide ligand for LanCL1, we confirm a key role for LanCL1 in chronic neuropathic sensitisation, with little effect on inflammatory hypersensitivity or physiological nociception. LAT8881 reversed mechanical allodynia in multiple rodent neuropathic models, including chronic constriction injury, where it suppressed spontaneous ectopic firing in vivo at the dorsal root ganglion (DRG), wind-up, and spontaneous activity in wide dynamic range neurons in the dorsal horn. It also induced membrane potential hyperpolarisation and suppressed spontaneous and primary-afferent-mediated excitatory events in ex vivo spinal cords. To identify protein targets of LAT8881, a photoaffinity conjugate of the active metabolite was used to pull down LanCL1 as the binding target in the spinal cord. This was validated with siRNA knockdown of LanCL1 in DRG, which blocked LAT8881 activity. Immunohistochemical analysis revealed a functional reorganisation of LanCL1 in neuropathic models, with reduced cytosolic expression in the DRG and increased expression in satellite glia. These findings establish LanCL1 as a critical mediator of neuropathic hypersensitivity and a prime target for clinical translation.
Simultaneous bilateral total knee replacement (SBTKR) is increasingly used to manage advanced bilateral knee osteoarthritis, particularly in India, where the disease affects approximately 22-39% of the population. Although SBTKR offers advantages such as single anesthesia, reduced hospital stay, and lower overall costs, it is accompanied by significant clinical and medicolegal concerns, particularly in high-risk populations. This review explores the clinical outcomes and litigation landscape of SBTKR in India, analyzes landmark legal cases, and proposes strategies to enhance both surgical safety and medicolegal accountability. A narrative review was conducted using the literature from PubMed, Scopus, and Indian legal databases. Clinical data were synthesized from studies published between 2000 and 2025. Legal precedents were drawn from consumer forum judgments and higher court rulings relevant to orthopedic malpractice and informed consent issues. Contemporary evidence indicates that SBTKR is as safe as staged procedures in well-selected patients. However, perioperative complications, such as infections, thromboembolic events, and unanticipated systemic deterioration, continue to trigger litigation. Legal case analysis revealed that lapses in preoperative evaluation, absence of cardiology clearance, and inadequate or undocumented consent were pivotal in determining the judicial outcomes. Conversely, detailed documentation and adherence to guidelines significantly strengthened the defense positions. Optimizing patient selection, enforcing thorough informed consent, maintaining comprehensive records, and integrating multidisciplinary preoperative assessments are crucial for enhancing both clinical and legal outcomes of SBTKR. Establishing robust institutional protocols and medicolegal training can mitigate the risk of litigation in orthopedic practice.