Randomized clinical trials are a mainstay of medical research, but have drawbacks including time and cost. Bayesian adaptive trials can improve the speed and efficiency of clinical trials and are an increasingly common trial design in critical care. However, the complexity of Bayesian adaptive trials may prevent clinicians from easily interpreting their results. Do intensivist physicians perceive, understand, and accept results from Bayesian adaptive clinical trials differently than results from traditional frequentist trials when presented with otherwise identical data? We surveyed US intensivists from March through April 2022 about their perceptions of Bayesian adaptive trials. Within the survey, participants were randomized to read an abstract for a hypothetical new sepsis drug trial that used either Bayesian adaptive methods or traditional frequentist methods, with both abstracts based on the same simulated trial data. Participants then were asked about perceived understanding, validity, and general acceptance of the trial's methods and results. Survey responses were compared between experimental groups using Mann-Whitney U tests and ordinal logistic regressions. We received complete results from 273 of 592 eligible physicians (response rate, 46.1%). Participants in the Bayesian group reported lesser understanding of the methods (mean rating in frequentist vs Bayesian groups, 3.18 vs 2.85; P < .001) and the results of the trial (mean rating, 3.36 vs 3.00; P < .001) compared with the frequentist group. Participants in the Bayesian group also expressed greater concerns about trial validity (eg, mean rating about the risk of type 1 error, 2.70 vs 2.99; P = .001) compared with the frequentist group. Participants in both groups reported similar beliefs about acceptance of trial results (eg, mean rating in frequentist vs Bayesian group about the effectiveness of the study drug, 3.87 vs 3.86; P = .47). Our results show that despite lower perceived understanding of Bayesian trials and skepticism about elements of their validity, no substantive differences were found in intensivist physician acceptance of Bayesian trial results compared with frequentist trial results. CHEST Critical Care 2026; 4(2):100264.
Accurate placement of the endotracheal tube (ETT) is critical for ensuring optimal care for patients requiring mechanical ventilation and preventing potential complications. ETT positioning can be assessed using several methods, with chest X-ray (CXR) being the most precise. Radiologists evaluate whether the ETT requires adjustment by measuring the distance between the distal tip of the ETT and the tracheal carina. This study presents the development of a machine learning model to detect and measure ETT position on adult CXRs and evaluates its performance. Six physicians annotated ETT and trachea locations on a dataset of 3856 CXRs. The U-Net-based model was then trained to generate trachea and ETT segmentations. After post-processing steps, an estimate of the distance between the distal tip of the ETT and the tracheal carina was found. It was demonstrated that the trained model is capable of estimating the position of the ETT and calculating the distance from the tube tip to the tracheal carina. The Dice index for the segmentations on the external validation subset for the trachea and ETT was 89.2% ± 9.0% and 87.8% ± 16.9%, respectively. The estimated absolute error on the external validation subset was 4.72 mm. This model represents a promising tool to support clinicians, particularly in Intensive Care Units, where correct intubation and effective ventilation are critical. It may also be integrated into clinical workflows to facilitate patient management and enhance patient safety.
In patients with acute drug poisoning, aspiration pneumonia complicated by respiratory failure is associated with prolonged hospitalization and increased mortality. However, the association between imaging findings at presentation and subsequent clinical course has not been fully evaluated. We investigated the association between lung injury findings on initial chest computed tomography (CT)-defined as peribronchial ground-glass opacities and/or consolidation-and clinical course and health care costs in patients with acute drug poisoning. Among 83 patients transported to our emergency department for intentional overdose or acute drug poisoning between January and August 2023, we retrospectively analyzed 57 patients who underwent chest CT at initial presentation. Patients were divided into CT-positive and CT-negative groups according to the presence of lung injury findings on initial CT. We compared patient characteristics, clinical findings, laboratory findings, clinical course, and fee-for-service costs between groups. We also performed multivariable analyses to identify factors associated with prolonged duration of intubation, prolonged length of stay, and increased medical costs. The median age was 43.5 (IQR, 27.2-57.0) years, and 17 patients were men. Lung injury findings were observed on chest CT in 16 patients (28.1%). Compared with the CT-negative group, the CT-positive group had a significantly higher proportion of patients requiring mechanical ventilation (81.2% vs 29.2%, p < 0.01), longer duration of intubation (2.0 vs 0 days, p < 0.01), longer hospital stay (6.0 vs 3.0 days, p < 0.01), and higher fee-for-service costs (Japanese yen (¥) 875,000 vs ¥487,000, p < 0.01). In multivariable analyses, CT positivity was significantly associated with prolonged duration of intubation (p < 0.01) and increased fee-for-service costs (p = 0.01). Approximately one-third of patients transported for acute drug poisoning who underwent chest CT at initial presentation had lung injury findings. These CT findings were significantly associated with prolonged duration of intubation and increased fee-for-service costs. However, because this was an exploratory retrospective analysis restricted to CT-imaged patients and residual confounding is likely, the results should be interpreted cautiously. Larger studies are needed to assess external validity.
Sarcopenia, assessed via computed tomography (CT), is an emerging prognostic tool in critically ill, pulmonary, and geriatric patients. Laboratory inflammatory markers such as C-reactive protein (CRP), interleukin-6 (IL-6), and neutrophil-to-lymphocyte ratio (NLR) are routinely obtained in these populations. Whether CT-assessed sarcopenia combined with laboratory markers offers superior prognostic accuracy over either measure alone remains unclear. To systematically evaluate the prognostic value of CT-assessed sarcopenia, alone or combined with laboratory inflammatory/nutritional markers, for predicting mortality, mechanical ventilation duration, and ICU length of stay in critically ill, pulmonary, and geriatric patients. MEDLINE/PubMed, Scopus, Embase, and Cochrane Library were searched from inception to December 2024. Observational studies (prospective or retrospective cohorts, case-control) that reported CT-based sarcopenia assessment alongside at least one laboratory inflammatory marker and at least one clinical outcome were included. Two reviewers independently screened studies, extracted data, and assessed methodological quality using the Newcastle-Ottawa Scale (NOS). Random-effects meta-analysis was performed; heterogeneity was assessed using the I² statistic. Twenty-five studies encompassing 12,347 patients were identified. The pooled odds ratio for mortality in sarcopenic versus non-sarcopenic patients was 2.28 (95% CI: 1.83-2.83; I² = 22.1%) across critically ill ICU cohorts. In COVID-19 pulmonary populations, pooled OR for in-hospital mortality with low skeletal muscle mass was 5.84 (95% CI: 1.07-31.83). CT-derived muscle measurements correlated inversely with CRP (r = -0.315), fibrinogen (r = -0.392), D-dimers (r = -0.363), and WBC count (r = -0.287). Combined CT-sarcopenia and inflammatory marker models outperformed conventional scoring systems (APACHE II, SOFA, CURB-65, PSI). CT-assessed sarcopenia, when integrated with laboratory inflammatory markers, provides a robust, mechanistically grounded, and clinically accessible multimodal prognostic framework across critically ill, pulmonary, and geriatric populations.
The Health Insurance Review and Assessment Service (HIRA) in South Korea assesses and grades primary and secondary healthcare institutions according to their management of chronic obstructive pulmonary disease (COPD). This study examined whether changes in institutional quality assessment grades were associated with variations in the concurrent risk of acute COPD exacerbations. Using national HIRA claims data, we identified 36,218 patients with COPD treated at 873 non-tertiary medical institutions between May 2016 and April 2018. Institutions were stratified into three groups based on their grade trajectories from the 3rd (May 2016-April 2017) to the 4th (May 2017-April 2018) assessment periods: the 158 improved-grade (n=5,118), 526 maintained-grade (n=25,286), and 189 declined-grade (n=5,814) institution groups. We compared the incidence and severity of exacerbations among these groups during the 4th assessment period. Incidence rate ratios (IRRs) for exacerbations were estimated using multivariable negative binomial regression models to adjust for potential confounders. At baseline, improved-grade institutions exhibited significantly higher rates of pulmonary function testing (56.3% vs. 41.9%) and greater prescription of long-acting muscarinic antagonists (29.0% vs. 14.6%) compared with declined-grade institutions (p<0.001). During the 1-year outcome period (May 2017-April 2018), the incidence of moderate-to-severe COPD exacerbations was considerably higher in the declined-grade group (29.2%) than in the improved-grade group (26.1%) (p=0.008). In the negative binomial regression analyses using the maintained-grade group as the reference category, patients treated at improved-grade institutions had a significantly lower risk of exacerbations (adjusted IRR 0.864, 95% CI 0.795-0.939, p<0.001). This analysis of nationwide real-world claims data demonstrated that institutional improvement in COPD quality assessment grades was associated with a reduced concurrent risk of acute exacerbations in both primary and secondary care settings. These findings indicate that institutional indicators of guideline-aligned COPD care may correspond to clinically meaningful differences in patient-level outcomes.
To compare the clinical efficacy and safety of small-bore (≤ 14 Fr) versus large-bore (> 14 Fr) chest tubes in the treatment of pneumothorax. A retrospective analysis was conducted. Patients were categorized into small-bore and large-bore groups based on the initial drainage tube size. Outcomes, including treatment efficacy, drainage duration, lung re-expansion time, hospital stay, complication rates, and analgesic use, were compared between groups. Subgroup analyses were performed based on pneumothorax type as primary and secondary spontaneous pneumothorax. In the overall population of 95 patients (55 large-bore, 40 small-bore), no statistically significant differences were found between the two groups regarding treatment efficacy (90.9% vs. 80.0%, P = 0.063), drainage time, lung re-expansion time, or hospital stay. The large-bore group required a significantly higher equivalent dose of analgesics (P = 0.049). Complication rates were similar between groups. In patients with secondary spontaneous pneumothorax (SSP), the small-bore tube group demonstrated significantly shorter drainage duration and lung re-expansion time compared to the large-bore group (both P = 0.007). In this retrospective analysis, small-bore and large-bore chest tubes demonstrated comparable treatment efficacy for pneumothorax management, with no statistically significant difference observed between groups. The large-bore group required a higher equivalent analgesic dosage, although this finding is exploratory given the borderline statistical significance and absence of validated pain assessment instruments. In the SSP subgroup, small-bore tubes were associated with significantly shorter drainage duration and lung re-expansion time, though these findings warrant further prospective validation.
Background: Accurate endotracheal tube (ETT) insertion depth is critical in infants and young children, where tracheal malposition carries significant risk. Formula-based depth estimation is widely used at the bedside, but the performance of published formulas in children under two years of age admitted to a general PICU remains poorly characterized. Methods: A retrospective, single-center study was conducted at the PICU of King Saud Medical City, Riyadh. A total of 115 patients aged 1-24 months requiring orotracheal intubation were included. ETT depth was predicted using five established formulas: height-based [(H/10)+5], weight-based [W+6], ETT size-based [ETT×3], Lee weight-based [5.5+0.5W], and Lee height-based [3+0.1H]. Agreement between predicted and radiographically confirmed insertion depth was assessed using Lin's concordance correlation coefficient (CCC), Bland-Altman analysis, and clinical classification of predictions. Results: None of the five formulas achieved acceptable concordance (CCC < 0.75 for all). The height-based formula performed best among published formulas, with negligible bias and the highest proportion of clinically acceptable predictions. Both Lee formulas showed near-universal systematic underestimation and are not suitable for this age group. Over half of all intubations resulted in non-ideal ETT position on the first post-intubation chest X-ray. Novel cohort-derived regression equations outperformed all published formulas, with the weight-based equation (Depth = 0.385 × Weight + 9.145) emerging as the strongest predictor of insertion depth. Conclusions: No published formula achieved reliable concordance with radiographic ETT depth in children aged 1-24 months. The cohort-derived weight-based formula represents a more accurate bedside tool for this population and warrants prospective external validation. Post-intubation radiographic verification remains essential.
Despite growing recognition that nurses must be equipped with sustainability competencies to address climate-related health challenges, the psychological mechanisms through which nursing education fosters sustainability attitudes are not yet fully understood. This study examined the mediating role of clinical performance self-efficacy in the relationship between simulation-based learning quality and sustainability attitudes among undergraduate nursing students. A cross-sectional correlational design was employed with a main sample of 679 nursing students from four Egyptian universities. Data were collected using the CHEST, SECP Scale, and SANS_2. Mediation analysis used Hayes' PROCESS macro with 5000 bootstrap resamples. Simulation-based learning quality significantly predicted both self-efficacy (β* = 0.772) and sustainability attitudes (β* = 0.613). Self-efficacy partially mediated this relationship, accounting for 68.34% of the total effect (indirect β* = 0.419, Boot 95% CI [0.343, 0.494]). Nursing educators should design simulation curricula that deliberately cultivate self-efficacy while embedding sustainability content, producing clinically competent and environmentally responsible graduates.
Purpose To investigate whether deep learning models trained on chest radiographs (CXRs) rely on radiographic exposure parameters as shortcut features and to quantify the resulting biases under controlled confounding and natural exposure regimes. Materials and Methods In this retrospective study, CXRs from MIMIC-CXR (January 2011-December 2016), the Medical Imaging and Data Resource Center (MIDRC; August 2020-May 2022), and EmoryCXR (September 2008-February 2023) were analyzed for pneumothorax detection, coronavirus disease 2019 (COVID-19) diagnosis, and race classification. Dataset-provided labels served as the reference standard. Three exposure parameters (ExposureTime, XRayTubeCurrent, ExposureInuAs) were extracted from Digital Imaging and Communications in Medicine (DICOM) metadata. Models were trained under biased and balanced exposure-label alignments and evaluated on matched and reversed distributions. A priori screening additionally identified high-risk exposure regimes. Area under the receiver operating characteristic curve (AUC) was compared using the DeLong test. Results A total of 727,604 CXRs from 240,681 patients (mean age, 60 years ± 17 [SD]; 126,432 men, 114,128 women) were analyzed. For pneumothorax detection, AUC decreased from 0.94 (95% CI: 0.94, 0.95) to 0.56 (95% CI: 0.55, 0.58) on mismatched exposure distributions (ΔAUC = -0.38; P < .001). Similar declines were observed for COVID-19 (ΔAUC = -0.33; P < .001) and race classification (ΔAUC = -0.09; P < .001). The priori exposure-regimen screening revealed high-risk regimes within the natural distribution that were associated with reduced model performance compared with typical exposures. Conclusion Deep learning models trained on CXRs may exploit exposure parameters as shortcut features; exposure-regimen audits may flag high-risk conditions before clinical deployment. ©RSNA, 2026.
Background/Objectives: Adipokines are candidate biomarkers in critical illness due to their roles in immunity and metabolism, both profoundly altered in sepsis. Omentin-1, vaspin, and chemerin have been studied in selected septic cohorts, but not concurrently in a heterogeneous ICU population including both septic and non-septic patients. Methods: Prospective observational cohort of 200 consecutive ICU patients with 28-day follow-up. Biomarkers were measured by ELISA within 24 h of admission. Analyses included Mann-Whitney U tests, Spearman correlations, ROC curves, and logistic regression with APACHE II and SOFA as comparators. Results: Vaspin was significantly higher in septic versus non-septic patients (406.4 [190.0-799.6] vs. 275.8 [101.8-559.8] pg/mL; p = 0.009). Omentin-1 was elevated in 28-day non-survivors (34.4 [22.5-56.1] vs. 25.1 [15.0-48.4] ng/mL; p = 0.037; AUROC 0.599), but lost significance after APACHE II adjustment (p = 0.295). Chemerin trended lower in non-survivors (p = 0.099); in septic patients, it correlated inversely with SOFA (r = -0.43) and lactate (r = -0.40), both p < 0.001. IL-6 and IL-10 were higher in non-survivors; IL-10 predicted 28-day mortality (AUROC 0.783), comparable to APACHE II (0.785). Conclusions: Vaspin distinguishes sepsis in mixed ICU populations. Omentin-1 shows a severity-driven association with mortality that does not survive APACHE II adjustment (AUROC 0.599, poor standalone discrimination), while chemerin inversely tracks hypoperfusion markers in septic patients, suggesting a potential counter-regulatory role requiring mechanistic confirmation. Individually, these adipokines do not add prognostic value beyond established severity scores, but their biological orthogonality to classical cytokines warrants exploration in multi-marker panel studies.
Early identification of patients at risk of severe pneumonia during Omicron SARS-CoV-2 infection is critical for optimizing care and allocating resources. While clinical markers provide insights, imaging-derived radiomics features may enhance prognostic accuracy. We developed a multimodal predictive model combining Delta Radiomics features from serial chest CT scans with clinical data, including blood biochemical markers and lymphocyte subsets. The primary prediction target was severe/critical Omicron pneumonia during hospitalization. Mild and moderate cases were grouped as non-severe disease, whereas severe and critical cases were defined as the severe class for binary classification. The model was trained on 91 patients from the first center, internally validated on 23 patients, and externally tested on 32 patients from a second center. Machine learning algorithms including Logistic Regression, Random Forest, and MLP were applied, and a nomogram was constructed for individualized risk prediction. The combined model showed high discrimination in the training cohort and maintained favorable performance in the internal validation and independent external test cohorts, achieving AUCs of 0.885 and 0.875, respectively. The Delta Radiomics signature, particularly with MLP, showed comparatively stable predictive performance. These findings suggest the added value of temporal CT-derived radiomics when integrated with clinical biomarkers, although further validation in larger prospective cohorts is required. Integrating temporal imaging features with clinical data offers a non-invasive method for early prediction of severe/critical Omicron pneumonia, supporting individualized triage and more efficient allocation of medical resources.
Recreational drugs affect the cardiovascular system through distinct mechanisms; however, data regarding their cardiovascular impact in the emergency department setting is limited. This study aimed to assess the incidence of cardiovascular effects following recreational drug use in presentations to the emergency department, identify the main drug groups involved, and compare cases with and without cardiovascular effects. Data were extracted from the European Drug Emergency Network (Euro-DEN Plus) dataset from October 2013 to December 2021. Recreational drugs were categorised into ten main drug groups: opioids, cocaine, crack cocaine, cannabis, 3,4-methylenedioxymethamfetamine, amfetamine-type stimulants, gamma-hydroxybutyrate and gamma-butyrolactone, hallucinogens, benzodiazepines, and ketamine. Among 59,571 presentations, 13,905 (23.3%) involved cardiovascular effects. Cocaine (OR 3.19, 95% CI 2.99-3.39) and 3,4 methylenedioxymethamphetamine (OR 1.18, 95% CI 1.13-1.23) showed the strongest associations with cardiovascular features, including chest pain, palpitations, hypertension, and arrhythmias. Opioids (OR 0.35, 95% CI 0.31-0.38) and benzodiazepines (OR 0.38, 95% CI 0.32-0.44) were associated with less frequent cardiovascular features. Patients with cardiovascular features exhibited higher median values for temperature, heart rate, blood pressure, and respiratory rate (p <0.001). Cardiovascular features were associated with an increased risk of intubation (OR 1.91, 95% CI 1.70-2.15), critical care admission (OR 2.18, 95% CI 2.00-2.38), and mortality (OR 15.8, 95% CI 7.36-33.9). Cardiovascular effects were common in acute recreational drug toxicity. Cocaine and amfetamine-type stimulants increased the risk of chest pain and arrhythmias, with chest pain being a key indicator of acute coronary syndrome. Cardiovascular effects were more frequently observed with cocaine than with crack cocaine. Cannabis was positively associated with palpitations but not arrhythmias. Gamma-hydroxybutyrate and gamma-butyrolactone, opioids, and benzodiazepines were linked to hypotension. The presence of cardiovascular effects was associated with worse outcomes, underscoring the need for thorough cardiac assessment. Cardiovascular effects were present in almost a quarter of emergency department presentations with acute recreational drug toxicity, particularly involving cocaine and 3,4 methylenedioxymethamphetamine.
Neonatal radiography is essential in neonatal intensive care units (NICUs) for diagnosing and monitoring critical conditions. However, the use of ionizing radiation in fragile neonates - particularly in repeated chest and abdominal x rays - raises concerns about cumulative radiation exposure and its potential long-term health effects. This study aimed to quantitatively assess the entrance surface dose (ESD) received by neonates during chest and abdominal radiography in two NICUs in Saudi Arabia and to compare with the international diagnostic reference levels (DRLs). A prospective, quantitative study of 100 neonates (50 in each hospital) on clinically justified chest and abdominal radiographs with mobile digital x-ray units was conducted. ESD was estimated from technical exposure parameters [tube voltage (kVp), milliampere-seconds (mAs), and focus-to-skin distance (FSD)] using the NRPB-recommended method. Correlation analyses and multiple linear regression were conducted to find the dose variation predictors. The average ESD was 0.48 ± 0.18 mGy in Hospital A and 0.49 ± 0.08 mGy in Hospital B with no statistically significant difference between the two hospitals. These results are well over ~5-10 times the international neonatal DRLs. ESD was significantly correlated with mAs (r=0.67) and patient thickness (r=0.76), and with kVp (r=0.54) in a moderate level of association; however, kVp and mAs were only weakly correlated (r=0.11). Regression analysis showed that patient thickness, mAs, and kVp were significant independent predictors of ESD (adjusted R2 = 0.65, p < 0.001). Neonatal radiation doses were found to be significantly elevated compared with the international reference levels, highlighting the need for immediate optimization. Dose reduction techniques like protocol standardization, elevated kVp at low mAs setting, beam collimation, and filtration must be used. These findings provide baseline data for establishing regional neonatal DRLs in Saudi Arabia and support future optimization studies using anthropomorphic phantoms.
The optimal treatment of interstitial lung disease resulting from COVID-19 is unknown. We sought to investigate the effect of nintedanib, an antifibrotic medication, on interstitial lung disease in participants who survived severe SARS-CoV-2 infection. We conducted a double-blind, randomized, placebo-controlled trial at six sites across the United States. Participants were included if they had evidence of prior SARS-CoV-2 infection that required supplemental oxygen therapy and had interstitial lung disease (ILD) findings on chest imaging ≥ 30 days post-infection. Participants received either nintedanib or placebo (1:1 ratio) for 180 days. Primary outcome was change in forced vital capacity (FVC) at 180 days; other outcomes included changes in chest computed tomography imaging (qualitative and quantitative), six-minute walk distance, and patient-reported outcome measures. In total, 103 of the planned 170 participants were randomized (51 to nintedanib; 52 to placebo); the study closed to enrollment before target sample size was met. FVC at 180 days improved in both nintedanib (+147.55 mL) and placebo groups (+167.72 mL) but were not significantly different (difference, -20.17 mL; 95% CI: -138.54 to 98.20). Similarly, six-minute walk distance, diffusing capacity, qualitative assessments of chest imaging, and patient-reported outcome measures improved in both groups. Quantitative chest imaging, as measured by data-driven textural analysis, showed no difference in fibrotic score changes for those receiving nintedanib or placebo (-4.49 vs -4.06; difference, -0.43; 95% CI: -3.34 to 2.47). Administration of nintedanib in this limited trial did not result in improved outcomes for participants with post-COVID-19 ILD.
IgG4-related aortitis is an uncommon inflammatory condition that can closely mimic both acute aortic and coronary syndromes, posing a major diagnostic challenge in patients presenting with chest pain. A 64-year-old man with prior non-ST-elevation myocardial infarction (NSTEMI) and persistent angina presented with abrupt-onset, severe retrosternal chest pain and dynamic lateral ST-segment depression. Rising high-sensitivity troponin supported a working diagnosis of high-risk NSTEMI. During observation, he developed acute respiratory failure and hemodynamic collapse. Echocardiography revealed a large circumferential pericardial effusion with reduced left ventricular ejection fraction, without classic tamponade physiology. Contrast-enhanced computed tomography demonstrated a crescentic ascending aortic wall thickening consistent with Stanford type A intramural hematoma extending into the arch vessels. A pericardial window drained 550 mL of serohemorrhagic fluid, with transient improvement, but recurrent instability prompted emergent ascending aortic replacement and coronary bypass grafting. Despite maximal support, the patient died intraoperatively. Histopathological analysis revealed dense lymphoplasmacytic infiltration rich in IgG4-positive plasma cells and storiform fibrosis, confirming IgG4-related aortitis. This case highlights the ability of IgG4-related aortitis to mimic both intramural hematoma and acute coronary syndromes, illustrating a critical diagnostic blind spot in acute cardiovascular care, particularly when imaging findings, clinical presentation, and intraoperative observations are discordant.
Complications of pregnancy and childbearing are one of the most important public health concerns worldwide. Postpartum sepsis remains a leading cause of maternal morbidity and mortality. Early recognition and timely intervention, including surgical source control, when necessary, are critical for improving outcomes. We report a 29-year-old gravida 2 woman with a history of opioid use, malnutrition, and very low socioeconomic status. She presented 10 days after a preterm vaginal delivery at 24 weeks' gestation with severe sepsis. She developed refractory septic shock, with evidence of endometritis, salpingitis, empyema, and renal microabscesses. Blood cultures grew methicillin-resistant Staphylococcus aureus (MRSA). Despite aggressive fluid resuscitation and broad-spectrum antibiotics, her condition deteriorated, necessitating a total abdominal hysterectomy with bilateral salpingectomy and chest tube insertion on postpartum Day 14. The patient improved postoperatively and was discharged 14 days after surgery. This case highlights the importance of early recognition of postpartum sepsis, rapid initiation of empiric broad-spectrum antibiotics, and multidisciplinary management. Risk factors such as comorbidities, malnutrition, and low socioeconomic status may increase disease severity and complicate management. In cases unresponsive to medical therapy, surgical source control can be lifesaving, even following vaginal delivery. Clinicians should maintain a low threshold for aggressive intervention in high-risk postpartum patients. Early diagnosis, multidisciplinary care, and timely surgical intervention are key to reducing maternal morbidity and mortality.
Catastrophic antiphospholipid syndrome (CAPS) is a rare, life-threatening condition with 30% mortality that poses diagnostic challenges during pregnancy due to overlap with preeclampsia and HELLP syndrome. We report a woman in her 30s who developed probable CAPS following emergency cesarean delivery at 22 weeks for severe preeclampsia. Unlike typical CAPS presentations, our patient lacked characteristic cutaneous manifestations, instead presenting with progressive cardiac, pulmonary, and renal dysfunction persisting despite delivery. Serial chest radiographs showed significant pulmonary edema and worsening bilateral pleural effusions, requiring noninvasive positive pressure ventilation and chest tube placement. The patient improved with supportive care and was discharged from ICU after 7 days. This case emphasizes the importance of considering CAPS in patients with persistent multiorgan dysfunction following delivery, even without typical cutaneous findings. Recognition of atypical presentations may facilitate timely intervention and improve patient outcomes.
The use of ultrasound (US) to guide percutaneous thoracic interventions improves safety and effectiveness of procedures and leads to reduced healthcare costs. A taskforce was convened to produce a statement on various clinical aspects of these procedures. The taskforce included respiratory physicians and nurses, thoracic surgeons, radiologists, and patient representatives. The statement covers the following procedures: thoracentesis, chest tube/indwelling catheter, medical thoracoscopy, and percutaneous biopsies of lung, pleura, mediastinum and cervical lymph nodes. Systematic searches were carried out for 18 PICO questions under five major topics to inform the writing of the statement. Narrative synthesis of the evidence from relevant literature is presented for each topic. Surveys and interviews with patients who underwent US-guided interventions were conducted to explore patient perspectives. Review of evidence is presented on: the use of US-guided interventions in diagnostic and treatment pathways for pleural and thoracic diseases (Section 1), comparative data on type/size of biopsy, chest tube size and disease outcome, optimal settings for procedures and portable ultrasound (Section 2), US specific methodology and association with outcomes, real-time US guidance for different interventions and contrast-enhanced US in procedure guidance (Section 3), diagnostic yield/treatment success and complications (Section 4) and training requirements (Section 5). Major themes emerging from patient surveys and interviews are presented in Section 6. Recommendations for future research conclude the statement. The use of US to guide percutaneous thoracic procedures is reported to show higher success and lower complication rates in the reviewed evidence. Further research is needed to better inform the procedural settings, techniques, and training.
Penetrating aortic ulcer (PAU) is a rare but highly lethal manifestation of acute aortic syndrome (AAS), most commonly seen in elderly patients with advanced atherosclerosis. Ascending aortic involvement is particularly uncommon but carries a high risk of rupture, hemopericardium, and cardiac tamponade. We present the case of a 33-year-old male with longstanding poorly controlled hypertension who presented to a community hospital with chest pain and syncope. Initial evaluation suggested acute coronary syndrome; however, computed tomography angiography revealed rupture of a penetrating ascending aortic ulcer with intramural hematoma and hemopericardium. The patient underwent prompt helicopter transfer to a tertiary care center and emergent surgical repair. He had an excellent postoperative recovery and remains well on follow-up. This case highlights the importance of maintaining clinical suspicion for acute aortic pathology, the diagnostic utility of computed tomography angiography, and the critical role of rapid systems-based coordination in achieving favorable outcomes in this high-mortality condition.
Coronary artery bypass grafting (CABG) is the gold standard treatment for advanced coronary artery disease (CAD). Postoperative complications can be life-threatening, particularly in patients with comorbidities. A 63-year-old male with triple-vessel CAD, diabetes mellitus, hypertension, obesity, and asthma underwent on-pump CABG using bilateral internal mammary artery grafts. The early postoperative course was complicated by traumatic sternal wound dehiscence following a fall on postoperative day 6, resulting in anterior chest wall dehiscence, rib fractures, and displaced sternal wires. Emergency re-exploration and modified Robicsek sternal closure were performed. The patient subsequently developed critical illness polyneuropathy and myopathy overlap syndrome (CIPNM), which gradually improved with supportive management and rehabilitation. He later developed deep sternal wound infection caused by Pseudomonas aeruginosa requiring prolonged targeted antibiotic therapy, repeated debridement, negative pressure wound therapy, removal of sternal wires, and pectoralis major flap reconstruction. Additional complications included arrhythmia, difficult airway management, acute kidney injury, pleural effusion, and electrolyte disturbances, all of which were managed successfully. Following eight months of coordinated multidisciplinary care and rehabilitation, the patient achieved complete wound healing and restored functional capacity. This case illustrates the complexity of sequential post-CABG complications and emphasizes the importance of early recognition, multidisciplinary intervention, and structured rehabilitation in achieving favorable outcomes.