Severe acquired brain injury (sABI) is a major challenge in post-acute care, affecting disability, quality of life, and healthcare resources. Traditional sequential care from acute units to rehabilitation often fails to meet the needs of complex patients. Interdisciplinary co-management between Neuro-ICU and Intensive Neurorehabilitation Unit (INRU) has been proposed to enhance continuity of care and optimize resource utilization. we analyzed 173 patients admitted to the INRU over three semesters: T1 (pre-implementation, n = 64), T2 (transition, n = 50), and T3 (co management, n = 59). The model involved joint management by a neurointensivist and an internal medicine specialist with expertise in neurorehabilitation, including a multidisciplinary assessment of clinical stability and the appropriateness of the rehabilitation pathway. Median age was 68.3 years [IQR 19.8], 60% male, with no differences across semesters. Co-management reduced length of stay (LoS) (68 vs 53 days) and urgent Emergency Department (ED) transfers (29.7 vs 18.6%), while stabilizing MDRO colonization despite higher admission prevalence. Transfers to rehabilitation units increased (23.8 vs 59.3%), long-term care admissions decreased (28.6 vs 13.6%), and mortality dropped from 7.9% to 3.4%. Negative outcomes (urgent ED transfers, long-term care admission and death) decreased from 56% to 25% (p = 0.003). Co-management enhances continuity of care, integrates acute and rehabilitative goals, and improves outcomes in complex patients. Structured interdisciplinary collaboration, coordinated by the internist-rehabilitation specialist, facilitates optimization of care pathways. Limitations include the retrospective, single center design and potential temporal bias. Further prospective and multicenter studies are needed to confirm its clinical and organizational benefits.
Emergency and critical care medicine requires the rapid synthesis of heterogeneous clinical data under extreme time constraints. Early artificial intelligence tools lacked the flexibility to manage real-world patient heterogeneity. Large language models (LLMs) offer a paradigm shift by demonstrating advanced natural language understanding, cross-task generalization, and context-sensitive reasoning, thereby bridging the gap between fragmented algorithms and holistic clinical decision support. The effective deployment of these models is grounded in four methodological pillars: domain adaptation, knowledge integration, multimodal and temporal modeling, and transparency. Domain adaptation and knowledge integration specifically empower the context-sensitive reasoning required for high-stakes intensive care. This theoretical framework enables their application across clinical decision support, documentation optimization, medical education, and clinical research. Integrating continuous physiological waveforms with multi-omics data facilitates dynamic risk stratification for complex conditions like sepsis, while natural language-to-structured query language capabilities accelerate clinical data extraction and quality improvement. The transition of LLMs from experimental settings to routine clinical deployment remains constrained by model hallucinations, multimodal integration barriers, and unresolved ethical governance. Sustainable implementation requires a human-in-the-loop copilot design, rigorous multicenter prospective validation, and transparent regulatory frameworks. Addressing these challenges is essential to ensure that technological innovations safely translate into measurable improvements in patient survival and clinical outcomes.
This study aimed to evaluate the effects of an integrated nursing model on systemic inflammation, oxygenation, and clinical outcomes in children with severe respiratory failure. Children with severe respiratory failure requiring invasive mechanical ventilation for ≥72 hours were consecutively enrolled. Participants were allocated according to admission period into a routine nursing group (2023) and an integrated nursing group (2024-2025). The integrated nursing model involved multidisciplinary assessment, coordinated care planning, and continuous nursing evaluation. Primary outcomes included changes in inflammatory markers (interleukin-6, tumor necrosis factor alpha, and C-reactive protein), while secondary outcomes included oxygenation indices (PaO2/FiO2), duration of mechanical ventilation, pediatric intensive care unit length of stay, and complications. Data were analyzed using independent-sample tests, chi-square tests, and linear mixed-effects models. Compared with routine nursing, integrated nursing was associated with greater reductions in interleukin-6, tumor necrosis factor alpha, and C-reactive protein over time and faster improvements in oxygenation indices. The integrated care group also had shorter mechanical ventilation duration and pediatric intensive care unit length of stay, and a lower incidence of ventilator-associated pneumonia. Integrated nursing may improve inflammatory control, oxygenation, and clinical outcomes in critically ill children with severe respiratory failure. Further multicenter randomized studies are warranted.
Rates of preterm birth and low birthweight remain high in the USA, in part due to perinatal poverty and societal underinvestment during a crucial window of human development. In 2024, Rx Kids was launched in Flint, Michigan, providing every expectant mother with unconditional cash transfers during pregnancy and infancy. It is the first cash transfer programme in the USA with universal eligibility (ie, community wide and no means testing) that targets the perinatal period. This study aimed to estimate the impact of Rx Kids on birth outcomes. In this population-based study, we used administrative data from the Michigan Department of Health and Human Services for all births in the state of Michigan, USA, and a quasi-experimental study design. Our study population comprised all infants born from Jan 1, 2021, to June 30, 2025, to women aged 16 years and older. The primary outcomes were preterm birth (<37 weeks) and low birthweight (<2500 g). Secondary outcomes included small for gestational age, admission to the neonatal intensive care unit, smoking in the third trimester, and prenatal care adequacy. We used a difference-in-differences strategy to estimate the adjusted mean change for the outcomes in Flint after implementation of Rx Kids relative to changes in a comparison group of matched cities. We also assessed several subgroups and the underlying assumptions of our difference-in-differences strategy. In 2021-23, the 3 years before the implementation of Rx Kids, 15·1% (445 of 2940) of births in Flint were preterm and 15·8% (465 of 2943) were low birthweight. Relative to the matched cities, Rx Kids was associated with a decrease in the preterm birth rate by 2·7 percentage points (95% CI -4·6 to -0·8; p=0·0075) and in the proportion of infants born with low birthweight by 4·2 percentage points (-6·0 to -2·4; p<0·0001). Corresponding to these reductions, Rx Kids was associated with fewer admissions to the neonatal intensive care unit by 4·4 percentage points (-6·5 to -2·4), less smoking in the third trimester (-1·7 percentage points [-2·4 to -0·9]), and more adequate prenatal care (5·7 percentage points [1·8 to 9·7]). The improvements in low birthweight, very low birthweight, very preterm, smoking in the third trimester, and prenatal care adequacy were most robust to alternative model specifications. The estimates for the primary outcomes were larger in magnitude for women who were non-Hispanic Black, nulliparous, and insured by Medicaid. With significant reductions in adverse birth outcomes, the treatment of perinatal poverty with a place-based intervention as replicable and scalable as Rx Kids has important implications for infants and society. These findings suggest that the economic hardship of the perinatal period, starting in utero, contributes to adverse outcomes and is addressable. Charles Stewart Mott Foundation and the Jamie and Denise Jacob Family Foundation.
The levels of alpha-1-antitrypsin (AAT) peptides could be used as prognostic biomarkers in critically ill patients, and peptide treatment has therapeutic efficiency in experimental sepsis. However, the regulation of AAT peptides in M. musculus is unknown, although they may be prerequisites for peptide-based therapies. This study aims to quantify murine AAT peptides and investigate their regulation during experimental sepsis.LC-MS/MS was used to quantify six AAT peptides from two murine AAT isoforms in plasma of septic mice.Peptide mC36-2 is the most abundant and significantly regulated murine AAT peptide, with approximately 20-fold higher level than in critically ill patients. In contrast, the upregulation of peptide C42 in septic patients is absent in mice; thus, it may represent a specific marker of human disease. Nevertheless, the increase and kinetics of mC36 during experimental sepsis reflect our observations in patients.In summary, the conserved upregulation of AAT peptides reflects important pathophysiological mechanisms of severe infections; thus, peptide levels can be used as predictive biomarkers in experimental and clinical sepsis. Although species-specific differences exist and need to be considered, quantification of AAT peptides might help to characterize individual immune responses and build the foundation for novel therapeutic approaches in pre-clinical and clinical research.
Military personnel frequently act as first responders in complex tactical-medical scenarios where they must make critical decisions under pressure and coordinate with civilian emergency services. Traditional simulation methods have limitations in replicating the stress and cognitive load inherent to these contexts. Virtual reality (VR) allows the recreation of high-demand scenarios, enabling the assessment of decision-making under operational pressure. A pre-post quasi-experimental study was conducted with 38 active-duty military personnel, who completed two VR scenarios: a mass casualty incident (MCI) and a tactical combat casualty care (TCCC) scenario, following a counterbalanced crossover design. The primary outcome was the accuracy of decision-making across two VR scenarios (MCI and TCCC). Secondary outcomes included physiological stress response through salivary biomarkers, neurophysiological metrics in a subsample and subjective experience assessed through a focus group. The analysis included descriptive statistics, paired t or non-parametric tests, linear mixed models for biomarkers and a qualitative thematic analysis. In the tactical scenario, participants showed a 76.7% accuracy rate, with variability in decisions under fire and airway prioritisation. In the MCI scenario, high accuracy was observed in triage items but errors occurred in more complex situations. Biomarkers showed moderate increases with no significance in univariate analyses but mixed models revealed effects of scenario type and exposure order. EEG metrics identified resilient, intermediate and vulnerable profiles, with signs of mental fatigue in high-demand phases. VR appears to be a useful tool for evaluating decision-making under pressure and for complementing training in tactical-medical scenarios, although this study does not provide direct evidence of improved learning outcomes.
Educational initiatives that address the gap between basic/preclinical and clinical practices are important to effectively translate basic science discoveries to benefit patients. The ILAE Neurobiology Commission conducted a pilot project aimed at exposing basic and preclinical scientists engaged in epilepsy research to general clinical issues pertaining to the diagnosis and care of people with epilepsy. This aim was addressed through a two-week-long, on-site clinical training program for 50 basic scientists in 21 epilepsy centers across 18 countries in the six ILAE regions (with a maximum of 3 basic scientists per center). The learning objectives and the training module were discussed and defined by the project organizing committee, which consisted of Neurobiology Commission members and a team of epileptologists representing different geographical regions. The training activities were conducted at each epilepsy center under the local supervision of clinical tutors. Each basic scientist was exposed to 50.3 ± 23.3 (range 16-89) hours of intensive and dedicated clinical training, coordinated by 2-3 tutors per center, assisted by 6.8 ± 3.6 colleagues. A structured test consisting of 17 general clinical epilepsy questions was completed by the trainees before and after the training activity. The learning assessment was based on the comparison between responses to the exit and entry tests. After the on-site clinical exposure, the proportion of correct answers increased to 87% compared to 61% in the entry test. Structured post-training questionnaires demonstrated very high satisfaction of trainees and all involved tutors across the different aspects of the training module. This global pilot study demonstrated that on-site attendance by basic scientists in specialized clinical settings up-scaled their knowledge of clinical epileptology and facilitated networking with clinicians. Expansion of this pilot to further centers should be considered to understand how exposure to clinical practice affects research direction and quality of translational epilepsy research. PLAIN LANGUAGE SUMMARY: Epilepsy research has long benefitted from collaboration between scientists and clinicians. Early exposure of researchers to people with epilepsy and their care teams may strengthen future impact. This pilot study tested a two-week immersive experience where small teams of basic scientists shadowed clinicians during their work at hospitals around the world. Questionnaires showed high satisfaction among both groups. Results support expanding such training, with the backing of the International League Against epilepsy and aligned centers, to build understanding, interest, and long-term commitment, ensuring bench research is informed by and translates to clinical practice and improved quality of life for patients.
Necrotizing enterocolitis (NEC) is a devastating gastrointestinal disease in preterm infants, characterized by exaggerated inflammation and poorly understood pathogenesis. Aryl hydrocarbon receptor (AhR) signaling has been shown to reduce intestinal inflammation in colitis models. In these models, a microbial-derived AhR ligand, Urolithin A (UroA), has demonstrated anti-inflammatory properties and improved gut barrier function. We hypothesize that UroA attenuates inflammation and enhances epithelial barrier integrity in an in vitro NEC-in-a-Dish model. Enteroids derived from human neonatal intestinal tissue were pretreated with 100 µM UroA or 0.1% DMSO (vehicle) before a 6-h incubation with dysbiotic enteric bacteria cultured from an infant with NEC totalis (NEC-in-a-Dish). RNA sequencing was performed and analyzed for pro-inflammatory cytokine expression and pathway enrichment. Epithelial barrier integrity was evaluated using a fluorescein-isothiocyanate-dextran permeability assay on two-dimensional monolayers. UroA pretreatment decreased pro-inflammatory cytokine expression and enhanced barrier integrity. Transcriptomic analysis showed downregulation of NOD-like receptor, IL-17/Th17, NF-κB, and TLR signaling, and upregulation of AhR-dependent genes involved in antioxidant responses. UroA reduces inflammation and strengthens epithelial barrier integrity in a NEC-in-a-Dish model through a variety of mechanisms. These findings support further investigation of dietary-derived metabolites as potential preventative strategies for NEC in preterm infants. Urolithin A (UroA), a microbiota-derived metabolite, reduces inflammation and enhances epithelial barrier integrity in a human neonatal in vitro model of necrotizing enterocolitis (NEC). This study is the first to demonstrate the protective effects of UroA in the neonatal small intestinal epithelium using a NEC-in-a-Dish model system. It also expands on the current understanding of the mechanism of action of UroA by revealing modulation of key inflammatory and oxidative stress pathways in neonatal tissue. These findings identify UroA as a promising candidate for dietary-based prevention strategies targeting epithelial injury in NEC.
Sepsis is a life-threatening condition associated with significant morbidity and mortality worldwide. The emergency department (ED) plays a crucial role in the early recognition and management of sepsis, as delays in treatment are strongly associated with worse outcomes. Although sepsis management guidelines and care bundles have been widely implemented to standardize and accelerate care, their impact on patient outcomes remains variably reported. This systematic review evaluated the effect of implementing sepsis management guidelines in EDs on both process indicators and clinical outcomes. A systematic search was conducted across PubMed, Scopus, Web of Science, and the Cochrane Library using a combination of controlled vocabulary and free-text terms related to sepsis, emergency care, and guideline implementation, yielding 4,309 records; after removal of duplicates and screening, eight studies met the inclusion criteria. Data extraction was performed using a standardized form capturing study characteristics, interventions, and outcomes, and risk of bias was assessed using the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool. The included studies comprised diverse designs, including before-and-after studies, retrospective cohort studies, observational studies, and one quasi-experimental trial. Overall, implementation of sepsis guidelines consistently improved process measures, including reduced time to antibiotic administration, increased lactate testing, improved blood culture collection, and higher compliance with sepsis bundles. However, effects on clinical outcomes were heterogeneous: some studies reported reductions in mortality, intensive care unit (ICU) admissions, and resource utilization, while others showed no significant mortality benefit despite improved process indicators. Additionally, some studies reported unintended consequences such as increased antimicrobial use and potential overtreatment. Most studies were judged to have a moderate to serious risk of bias, largely due to confounding and non-randomized designs. In conclusion, implementation of sepsis management guidelines in EDs is associated with consistent improvements in care processes and timeliness of treatment, but evidence for improved clinical outcomes, particularly mortality, remains inconsistent and is limited by study design and risk of bias; further high-quality studies are needed to establish causality, optimize implementation strategies, and balance timely treatment with antimicrobial stewardship.
Perioperative antithrombotic management in neurosurgery carries significant bleeding and thrombosis risks. This survey aimed to provide the first structured analysis of current practices, resource availability, and decision-making heterogeneity across the coordinated neurocritical care network in Lombardia (Lombardy) an administrative region in Northern Italy. This cross-sectional, region-wide survey involved all 19 hospitals performing neurosurgery in Lombardy. It analyzed multiple domains of perioperative anticoagulant management, including preoperative risk assessment, laboratory monitoring, use of bridging therapy, reversal strategies, and timing of pharmacologic thromboprophylaxis. The head of service collected responses from two to four experienced colleagues at each center. Participation was voluntary and anonymous, and no patient-level data were collected. Data were analyzed descriptively using R software; categorical variables are expressed as number (percentage) and continuous variables as mean± (SD)[median (IQR)]. The survey revealed marked variability across all domains, with clinical approaches remaining fragmented and largely driven by institutional culture rather than standardized protocols. A systemic lack of data collection on institutional postoperative hemorrhage and deep vein thrombosis epidemiology was found, with available data often based on subjective estimates. There is underutilization of formal thrombotic risk scores (e.g., Padua, IMPROVE) and predominantly reactive use of viscoelastic testing (ROTEM/TEG). Only 20.7% of respondents routinely involve both a Cardiologist and a Hematologist for multidisciplinary assessment. Furthermore, the timing of low-molecular-weight heparin administration varies widely: most responders delay initiation until postoperative day two to four after intracranial procedures, often deviating from guidelines recommending initiation within 24 hours when safe. The findings highlight the urgent need for structured, consensus-based perioperative anticoagulation pathways tailored to neurosurgical populations. Priority areas include standardizing venous thromboembolism prophylaxis timing and modality, promoting the systematic use of viscoelastic testing, and creating regional registries to track hemorrhagic and thrombotic events and improve evidence-based decision-making.
Disrupted cerebral blood flow is suggested to contribute to secondary brain injury after cardiac arrest (CA). This study aimed to investigate cerebral microcirculation after return of spontaneous circulation (ROSC) following asphyxial CA. We hypothesized that contraction of pericytes after ROSC compromises cerebral capillary blood flow. Transgenic C57BL/6NRj mice (n=19) of both sexes were studied. Mice were expressing tdTomato as a fluorescent reporter under the control of the platelet-derived growth factor receptor β promoter to label pericytes. Chronic cranial windows were implanted 3 weeks before the experiment. Four minutes of asphyxial CA was followed by cardiopulmonary resuscitation. Two-photon microscopy assessed cerebral hemodynamics in the same cohort of mice at both 3 and 24 hours after ROSC. Of 13 mice in the CA group, 9 achieved ROSC; 6 and 5 mice survived to 3 and 24 hours after ROSC, respectively. Arterial blood pressure was similar between groups 3 and 24 hours after ROSC. At 3 hours after ROSC, pial arteries and penetrating arterioles were constricted in the CA group compared with sham (arteriole diameter, 12.2 μm [95% CI, 10.9-13.4] versus 15.6 μm [95% CI, 13.8-17.5] in CA and sham; P=0.003). Similarly, first- and second- to third-order capillaries showed reduced diameters 3 hours after ROSC (first-order diameter, 3.9 μm [95% CI, 3.5-4.2] versus 5.3 μm [95% CI, 4.8-5.9] in CA and sham; P=0.002). The vasoconstriction was associated with slower red blood cell velocities throughout the capillary network (for second- to third-order capillaries upstream from venule; 0.78 mm/s [95% CI, 0.46-1.09] versus 2.14 mm/s [95% CI, 1.73-2.55]; P<0.001) and increased capillary flow stalling. Artery-to-vein mean transit time was increased and relative transit-time heterogeneity was decreased 3 hours after ROSC. By 24 hours after ROSC, vessel diameters, blood flow velocity, transit time, and capillary stalling were not different compared with sham. Cerebrovascular vasospasm 3 hours after ROSC was associated with impaired cerebral microcirculation and increased capillary flow stalling.
Interstitial lung diseases (ILDs) represent a heterogeneous group of disorders, which have in common persistent inflammation and/or pulmonary fibrosis, involving mainly but not exclusively the interstitium. This results in restrictive ventilatory physiology and limited respiratory reserve. Patients with ILD can have frequent exacerbations of their disease, with subsequent acute respiratory failure that may require admission to the intensive care unit (ICU). The diagnosis and management of ILD in the ICU presents unique challenges due to the paucity of evidence supporting survival benefits of organ support in this cohort of patients. This systematic review will be reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, and the protocol will follow the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) guideline. MEDLINE, Embase, Emcare and CENTRAL will be searched for studies published from inception to 2026, involving adult patients with ILD requiring invasive mechanical ventilation (IMV), with or without comparison to non-invasive respiratory support such as high-flow oxygen, non-invasive ventilation (NIV), continuous positive airway pressure or bilevel positive airway pressure. Eligible studies will include randomised controlled trials and observational studies (cohort and case-control) in adults with ILD and acute respiratory failure requiring IMV in the intensive care setting. Case series with fewer than 10 patients, non-human or in vitro studies and studies involving perioperative lung transplant or lung cancer as the primary diagnosis will be excluded. The primary outcomes assessed will be in-hospital and 1-year mortality, and secondary outcomes will include ventilator-free days, ICU and hospital length of stay, NIV failure, reintubation and postdischarge respiratory outcomes where available. Where feasible, meta-analysis will be conducted using a random-effects model. Heterogeneity will be assessed using the I² statistic. Prespecified subgroup analyses will be performed, including ILD subtype (eg, idiopathic pulmonary fibrosis (IPF) vs non-IPF), presence of pulmonary hypertension, timing of IMV initiation (early vs late), baseline lung function (forced vital capacity ≥50% vs <50%), ventilation strategy (lung protective vs non-specified) and geographical region (eg, Europe, North America, Asia). Sensitivity analyses will be conducted to evaluate robustness of results. Risk of bias will be assessed using the Cochrane Risk of Bias 2 tool (RoB 2) for randomised studies and the Newcastle-Ottawa Scale for non-randomised studies. The quality of evidence will be assessed by using the Grading of Recommendations Assessment, Development and Evaluation approach. This systematic review will be based on published data, and as such, no ethical approval is required. Findings from this study will be disseminated through peer-reviewed publications as well as presentations in healthcare-based settings. CRD420251265836.
Sepsis remains a critical challenge in intensive care, necessitating reliable animal models that accurately mimic human pathophysiological responses. While cecal ligation and puncture (CLP) is widely considered the gold standard, its inherent variability often limits reproducibility. This study aimed to optimize a fecal intraperitoneal injection (FIP) murine model by evaluating the impact of fecal preparation (fresh vs. lyophilized) and dosage (0.5-1.0 g/kg) on model stability. We systematically compared the optimized FIP model with the conventional CLP method in male BALB/c mice to define their respective pathophysiological characteristics and suitability for therapeutic screening. Fresh fecal suspensions significantly enhanced model reproducibility compared to dried preparations, which exhibited inconsistent virulence. An optimized FIP dose of 0.7 g/kg induced a hyperacute sepsis phenotype, characterized by rapid systemic bacterial dissemination and severe acute organ damage within 24 h. Crucially, semi-quantitative histological scoring confirmed that FIP triggered a synchronized, hyperacute injury spike across the lung, kidney, liver, and heart, whereas the CLP model exhibited a more protracted, progressive exacerbation of organ dysfunction through 48 h. Hematological analysis further revealed that while both models induced systemic inflammation, the FIP model provided a much sharper and predictable onset of severe leukopenia and multi-organ failure. The optimized FIP model, characterized by its procedural simplicity, high controllability, and superior reproducibility, serves as a robust platform for investigating the early, fulminant pathophysiological mechanisms of unmitigated sepsis. Conversely, the CLP model remains the preferred choice for studies focusing on protracted infection and chronic organ dysfunction. These findings provide a methodological framework for selecting appropriate sepsis models based on specific research objectives in experimental medicine. Not applicable.
We propose the concept of "renal congestion syndrome" as a pathophysiological construct describing a potential contributor to acute kidney injury (AKI) in the intensive care unit (ICU). This concept should be considered as hypothesis-generating rather than a validated clinical entity with established diagnostic or therapeutic implications. Growing experimental and clinical evidence supports a plausible contributory role in kidney dysfunction. However, interventional evidence is currently lacking, and the clinical utility of targeting congestion remains to be established. When renal venous pressure rises, hydrostatic pressure in Bowman's space and the interstitium increases. This reduces net ultrafiltration pressure and glomerular filtration rate, even if arterial pressure is preserved. Edema within the non-distensible capsule compresses tubules and peritubular capillaries, aggravating hypoxia and tubular injury. Lymphatic drainage may initially buffer this process, but fails with sustained congestion. In the ICU, congestion is common and multifactorial: fluid overload, right heart dysfunction, high intrathoracic pressures from ventilation, or intra-abdominal hypertension. Experimental data suggest that congestion may precipitate early loss of renal autoregulation, leaving kidneys vulnerable even at apparently normal mean arterial pressures. Moreover, it often coexists with hypotension, reducing mean perfusion pressure (MPP), further lowering renal perfusion pressure, and increasing the risk of AKI. Diagnosis relies on an integrated assessment combining clinical context with haemodynamic monitoring and, when available, imaging-based evaluation of venous congestion. Central venous pressure remains the standard reference for assessing central venous hypertension; however, its specificity for renal congestion is limited. Doppler ultrasound with Venous Excess Ultrasound (VExUS) score may improve detection and risk stratification, though interpretation can be confounded by mechanical ventilation or intra-abdominal hypertension. Management is conceptually aimed at relieving congestion while preserving renal perfusion. Based on physiological rationale and limited observational data, this may involve preventing fluid accumulation and implementing individualized decongestive strategies (e.g., fluid stewardship, diuretics when appropriate, or ultrafiltration when indicated). Haemodynamic-guided deresuscitation, integrating congestion markers with real-time MPP assessment, appears promising but remains supported only by feasibility data. Renal congestion-related mechanisms are likely frequent, under-recognized, and potentially reversible contributors to AKI in the critically ill patient. Systematic assessment of congestion-related mechanisms warrants further investigation. Whether their integration into haemodynamic evaluation improves clinical outcomes remains to be determined.
To evaluate the accuracy, stability, and dynamic BP tracking capability of a cuffless continuous non-invasive blood pressure (CNIBP) wearable system (Shenzhen Mindray Bio-Medical Electronics Co., Ltd.) to track dynamic blood pressure (BP) changes in intensive care unit (ICU) patients. A multicenter, prospective clinical trial enrolled ICU patients aged ≥ 12 years who required continuous invasive blood pressure (IBP) monitoring for ≥ 24 h. The mWear wearable monitoring system (Mindray) served as the test device, with IBP as the reference standard. The study followed the International Organization for Standardization (ISO) 81060-3:2022 guidelines to evaluate the accuracy, stability, and dynamic BP tracking. Forty-nine participants (mean age, 57.3 ± 18.7 years) were included in the study. The mean differences between CNIBP and IBP measurements for systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) were -0.31 mmHg, -0.81 mmHg, and -0.37 mmHg, respectively, all within the predefined 95% confidence interval (CI). The corrected experimental standard deviations (SD) were 5.3, 3.6, and 3.6 mmHg, respectively, consistent with the ISO 81060-3:2022 criteria (mean difference: -6 to 6 mmHg; corrected experimental SD: ≤10 mmHg). The Pearson correlation coefficient (PCC) exceeded 0.9, indicating a strong linear correlation. Stability assessments demonstrated that CNIBP remained within ISO error ranges over 24 h. For BP change-tracking ability, the median absolute error (E percent , 50th percentile) averaged ≤25%, and the 85th percentile averaged ≤50%, both of which met ISO requirements. The findings indicate that CNIBP device measurements are consistent with IBP readings in terms of accuracy, stability, and dynamic BP tracking capability within the ICU. This consistency effectively supports real-time hemodynamic assessment in critically ill patients.
The shift from reusable to single-use anaesthesia devices, such as laryngoscope blades, is increasingly questioned because of the financial and environmental costs of disposables. Validated disinfection methods enabling safe reuse could provide clinical, economic, and sustainability benefits. In this laboratory-based experimental study, disposable McGRATH™ X-blade video laryngoscope blades were artificially contaminated with Staphylococcus aureus and subjected to automated ultraviolet-C (UV-C) light-emitting diode (LED) disinfection under different reprocessing conditions. An integrated assessment was performed, including microbiological efficacy, material integrity after repeated UV-C exposure, estimated economic and environmental impact, and regulatory considerations. Results were compared with single-use, steam autoclaving, and chlorine dioxide wipe-based disinfection. UV-C disinfection reduced Staphylococcus aureus contamination to undetectable levels across all experimental conditions; unpackaged cleaned, uncleaned blades, and packaged uncleaned blades (n=6, n=5, and n=5, respectively). No visible degradation, functional impairment, or deterioration in image quality was observed after repeated UV-C exposure. Per-cycle cost was less than €0.20, and greenhouse-gas emissions were reduced by 92-94% compared with single-use. In contrast, autoclaving or chemical disinfection compromised blade usability. Automated UV-C LED treatment effectively disinfected McGRATH X-blades under controlled laboratory conditions, preserving material integrity and offering substantial environmental and economic advantages. This approach may support more sustainable anaesthetic practice where validated point-of-care reprocessing is implemented.
Situational awareness (SA) is a critical nontechnical skill for intensive care unit (ICU) physicians, underpinning safe decision-making and patient safety. Despite its importance, evidence regarding how SA is assessed and improved in ICU practice remains fragmented. To map the existing evidence on interventions and assessment methods for SA among physicians in adult ICUs, and to evaluate their reported effectiveness. Scoping review of randomised controlled trials, quasi-experimental studies, cross-sectional studies, and qualitative studies, conducted in accordance with PRISMA-Scr guidelines. MEDLINE, Web of Science, Scopus, and PsycINFO were searched from inception to July 2024. Reference lists and supplementary searches were performed. We included studies involving ICU physicians, residents and medical students working in adult ICUs that assessed or intervened on SA. Exclusions included studies limited to paediatric/neonatal ICUs, non-ICU staff, inter-unit handovers, reviews, opinion pieces and nonpeer-reviewed literature. From 991 records, 11 studies were included. Simulation-based training consistently improved SA and team co-ordination, while lecture-based training alone was largely ineffective. Crew resource management (CRM) courses increased self-reported awareness but had mixed effects on outcomes. Technological tools (e.g. dashboards, 3D visualisations) showed promise in enhancing early recognition of clinical deterioration and supporting decision-making. SA assessment was most frequently performed using the Situation Awareness Global Assessment Technique (SAGAT), though this remains impractical for real-time ICU use. Methodological quality was generally moderate, with small sample sizes and heterogeneity limiting quantitative synthesis. Simulation-based interventions and novel technological tools appear most effective in enhancing SA among ICU physicians, whereas CRM and didactic methods yield mixed results. The lack of validated, ICU-specific SA assessment tools represents a critical gap. Future research should focus on scalable, team-based training models, context-appropriate assessment instruments, and integration of technological decision-support to strengthen SA and improve patient safety.
Irrational use of intravenous (IV) proton pump inhibitors (PPIs) for stress ulcer prophylaxis (SUP) in critically ill patients increases the risk of adverse drug reactions (ADRs), and may lead to longer stays in the intensive care unit (ICU). A single-center, retrospective, observational study was conducted to assess the practices with prescribing IV SUP in critically ill adult patients treated at ICUs between January 2020-December 2022. Data was collected from electronic medical records, using a pre-designed checklist. Appropriateness of SUP administration was determined using the American Society of Health-System Pharmacists (ASHP) recommendations. Medical records of 1076 patients were analyzed; majority of patients (80.9%; n = 873) received IV SUP during their ICU stay, with the most commonly prescribed drug being omeprazole (99.2%). 75.5% of patients had no major or minor risk factors based on ASHP guidelines. The rationale of SUP was deemed appropriate in 51.7% of cases. Among patients treated at specific ICU wards, male patients were less likely (OR: 0.587 [95% CI: 0.345-0.998]; p = 0.048), while ventilated patients were more likely (OR: 2.525 [95% CI: 1.219-5.233]; p = 0.013) to receive SUP. Furthermore, ≥10 days of hospital stay corresponded to notable increase (OR: 4.076 [95% CI: 0.870-19.098]; p = 0.086) in the probability of receiving SUP. The results may provide a basis for developing protocols related to acid-suppressive therapy in critically ill adults, calling for heightened awareness and tailored interventions to optimize pharmacological care in ICU settings.
Early-life dysbiosis associated with Cesarean section (C-section) delivery is increasingly recognized as a modifiable risk factor influencing short- and long-term health outcomes. This multidisciplinary expert consensus summarizes the clinical implications of C-section on infant gut microbiota. It proposes evidence-based strategies to mitigate these effects, with a focus on the critical window of the first 1,000 days of life. A multidisciplinary panel of 16 pediatricians, neonatologists, pediatric gastroenterologists, and nutrition experts conducted a targeted narrative review of the literature to inform a structured expert consensus process and participated in an online structured consensus process. Seventeen consensus statements were developed and validated through discussion, expert voting, and commentary, supported by a targeted review of current scientific evidence. The expert panel reached consensus on the impact of C-section delivery on early microbiota composition and its clinical relevance, emphasizing that the rising prevalence of C-sections worldwide demands urgent attention. Experts unanimously emphasized the importance of exclusive breastfeeding as the primary strategy to support healthy microbiota development in infants born by cesarean section. When exclusive breastfeeding is not possible, evidence-based nutritional approaches, including selected prebiotics and probiotic strains with documented clinical efficacy, are recognized as promising alternatives for supporting microbial balance. Notably, the panel underscored that not all probiotics are equally effective and recommended shifting toward evidence-based strains shown to help restore gut dysbiosis in this population. Also, experts advocated for continuing microbiota-targeted support throughout the first 1,000 days of life, viewing this developmental window as a critical continuum rather than a limited early-life phase, while acknowledging the need for more long-term data. Additionally, education for healthcare professionals and parents about the long-term implications of C-section delivery was emphasized as a key enabler of the broader adoption of eubiosis-targeted strategies. Optimizing microbial colonization in infants born by cesarean section requires a multifaceted approach that prioritizes breastfeeding, supports judicious use of evidence-based nutritional interventions when needed, and emphasizes education and continuity of care across early life. By aligning clinical practice with emerging microbiome science, early-life interventions may reduce dysbiosis-associated risks and improve long-term health outcomes.
Wound infections caused by extensively drug-resistant Pseudomonas aeruginosa (XDR-PA) pose a significant clinical challenge with extremely limited treatment options. Polymyxin B (PMB) represents one of the last therapeutic lines of defence, yet its optimal route of administration (topical, intravenous, or combined) for deep tissue infections such as wounds remains to be further investigated. This study aimed to investigate the efficacy differences of different PMB administration routes (topical, intravenous, and combined therapy) in treating XDR-PA wound infections in mice, providing experimental evidence for optimizing clinical treatment regimens. One hundred and twenty Kunming mice were randomly assigned to five groups (n = 24 per group): (1) sham-operated group (uninfected); (2) infected untreated group; (3) infected + topical administration group (5 mg/kg); (4) Infection + intravenous administration group (5 mg/kg); (5) Infection + combined topical and intravenous administration group (2. 5 mg/ kg each). A full-thickness dorsal skin defect wound infection model was established in mice. Drug administration was in initiated 24 h post- infection and was performed once daily for four consecutive days. Daily observations and recordings were made of mouse body weight changes and wound erythema. Every 4 days post-infection, three mice were randomly selected and euthanized from each group for wound tissue collection to determine bacterial load. On days 6 and 17, wound tissue was collected for protein content analysis, cytokine (e.g., IL-1β, TNF-α) detection, and histopathological assessment. Compared to the untreated infected group, all administered treatment groups demonstrated therapeutic efficacy. The topical administration group exhibited the most pronounced wound healing promotion, it achieved the highest wound closure rate, fastest resolution of erythema and oedema, and optimal bacterial clearance efficiency. Additionally, it showed effective regulation of inflammatory response, and minimal histopathological damage. The intravenous administration group exhibited the next highest efficacy. The combination therapy group did not demonstrate synergistic effects superior to local monotherapy. Mice in the untreated infection group exhibited the slowest weight gain and delayed wound healing. Mice in the untreated infection group exhibited the slowest weight loss and delayed wound healing. Under the experimental conditions employed, topical application of PMB demonstrated superior efficacy to intravenous administration and combined therapy in treating wound infections in XDR-PA mice. Due to the equal total daily dose design (5 mg/kg for all treatment groups), the combination therapy group received a lower dose per route (2.5 mg/kg each) compared to the monotherapy groups (5 mg/kg via a single route). Therefore, no definitive conclusion can be drawn regarding potential synergistic or antagonistic effects of combination therapy based on this study design. This suggests that targeted local administration may represent a more effective and cost-efficient strategy for localized infections caused by resistant bacteria, which warrants further clinical translational research.