Dissociation is a multidimensional construct linked to suicide risk. However, it is unclear which dimensions of dissociation are most important to suicide risk, and whether they correlate with suicide ideation (SI), suicide attempts (SA), or both. Thus, the present study utilized multiple measures of dissociation to examine the differential relationships of distinct dissociation dimensions to SI and SA. Participants were 545 undergraduates, oversampled for suicide risk, including 141 with histories of SA and 255 with histories of SI but not attempts. Suicide history, dissociative symptoms, and potential covariates were measured via validated self-report questionnaires. In general, analyses indicated that dissociation was associated with both SI and SA among those with ideation. Regarding specific dimensions, depersonalization/derealization and zoning out best predicted SI, whereas reexperiencing best distinguished SA from those with SI only. The findings suggest that different types of dissociative experiences are associated with different aspects of suicide risk. Future research should continue to utilize updated, multidimensional models of dissociation to better understand the role of this construct in suicide risk.
Negative automatic thoughts feature centrally in psychiatric disorder but are rarely studied in the prediction of suicide attempts. This study tested whether negative automatic thoughts could prospectively predict suicide attempt or other suicide event (aborted or self-interrupted attempt, preparatory behavior or suicidal ideation resulting in hospitalization) within a 90-day window among high suicide risk patients. Sixty Veterans at high risk of suicide completed assessments of negative automatic thoughts at multiple timepoints over a 1-year period. Each assessment session was then coded according to whether the participant made a suicide attempt or had an other suicide event in the following 90 days. Generalized Estimating Equations (GEE) were used to evaluate the incremental utility of (1) negative automatic thoughts and (2) acquired capability for suicide on predicting 90-day suicide attempt or other suicide event over established suicide risk factors, including lifetime number of suicide attempts, concurrent suicidal ideation, depressive symptom severity and hopelessness. The odds of a 90-day suicide attempt were significantly greater with more frequent negative automatic thoughts (OR = 1.06 [95% CI 1.03-1.09], p < .001); however, negative automatic thoughts did not significantly predict a near-term other suicide event (excluding an actual attempt). Acquired capability did not add to the near-term prediction of either suicide attempt or other suicide event. The study was a secondary analysis of data collected from a small sample, and thus, findings require replication. Near-term suicide attempts were rare even in this high-risk sample. Nevertheless, findings provide preliminary evidence for depressionogenic thought content in suicide attempt risk, and suggest a more direct link between negative automatic thoughts and suicide attempt than posited in contemporary theories.
Self-injurious behaviors (SIBs) represent a major public health concern in the United States. Although sexual minority individuals experience disproportionately high rates of SIBs, research identifying population-specific risk factors remains limited. This study examined how stressful experiences common among sexual minority (SM) adults relate to the likelihood of SIBs in SM versus heterosexual adults. A community sample of adults aged 18-54 years (Mage = 30.52 years, SD = 9.66, 59.8% assigned female at birth) completed self-report and interview measures of trait-level SIB risk factors (emotional reactivity, disinhibition), stressful life experiences (childhood trauma, discrimination), and lifetime history of nonsuicidal self-injury (NSSI) and suicide attempts. One third of participants (33.3%) reported SM attraction, 48.2% identified as a racial/ethnic minority, and 42.3% earned a high school diploma or less. A substantial minority reported a history of NSSI (24.1%) and/or a suicide attempt (12.4%). SM versus heterosexual attraction was associated with both NSSI, r = .36, p < .001, and suicide attempts, r = .25, p < .001, at the bivariate level. SM attraction moderated the link between discrimination and the odds of a suicide attempt, OR = 4.10, p = .030, such that discrimination was positively associated with the odds of a suicide attempt among SM, p = .008, but not heterosexual participants, p = .643. These findings highlight that everyday discrimination exerts a disproportionate impact on the risk of suicide attempts among SM adults, emphasizing the importance of interventions that confront discrimination and minority stressors to mitigate these disparities.
Background/Objectives: The growing population of multicultural adolescents (MCAs) has become a vital focus for national health policy. Despite their increasing numbers, MCAs often encounter unique socioeconomic challenges and dietary issues that may heighten mental health vulnerabilities. This study aimed to assess the dietary behaviors of MCA and non-MCA and to explore the association between these behaviors and mental health outcomes, specifically generalized anxiety disorder (GAD) and severity of suicidal behavior. Methods: Using data from the 2024 Korea Youth Risk Behavior Survey, we analyzed the dietary behaviors of 44,796 adolescents, focusing on five key areas: breakfast consumption, fruit intake, caffeine drinks, sweetened beverages, and fast food. We also calculated a composite dietary behavior score and assessed mental health using the GAD-7 and a three-component suicidal behavior scale (including ideation, planning, and attempts). Results: MCAs experienced significant disparities in socioeconomic status and had a notably higher prevalence of suicide attempts compared to non-MCAs (p = 0.0107). In both groups, poorer dietary behaviors were linked to an increased likelihood of GAD and greater severity of suicidal behavior (ptrend < 0.05). This association with suicidal behavior severity was particularly pronounced in MCA (pinteraction = 0.0358). Conclusions: Dietary behavior is significantly associated with mental health issues among Korean adolescents. Given the vulnerabilities faced by MCA, it is essential to implement multifaceted policy support and targeted dietary interventions to improve outcomes for this population.
This study evaluated whether the complexity and temporal dynamics of environmental enrichment during the nursery phase are associated with piglets' threat-related responses and affective state using a multimodal approach. We combined an Attentional Bias Test (ABT) with bioacoustic measures, Qualitative Behavior Assessment (QBA), and biomarkers (hair cortisol and serum BDNF). In a commercial nursery setting, 675 piglets were allocated to three treatments: UNI (single continuous item: chains), ALT (chains plus an additional object rotated weekly), and SIM (continuous simultaneous provision of multiple objects). A subsample of 32 piglets underwent the ABT (UNI, n = 10; ALT, n = 11; SIM, n = 11). Most ABT measures related to threat-directed attention and space use showed no detectable treatment differences under the present protocol, and feeding latency was affected by stimulus exposure but not by treatment. In contrast, treatments differed in coping-related responses: UNI showed a higher frequency of excretions, ALT showed a longer standing-inactive duration, and SIM showed more escape attempts. Vocalizations were restricted to harsh grunts, with ALT showing longer harsh-grunt duration and higher total vocal output. QBA and biomarkers further differentiated treatments: SIM showed calmer/less tense expressive profiles, whereas UNI showed higher post-exposure hair cortisol and lower serum BDNF than the more complex conditions. Overall, enrichment-related differences were more consistently detected in coping-related behavior, QBA, and biomarkers than in ABT attentional measures, suggesting that enrichment implementation (stable vs. rotational) shapes partially dissociable behavioral and physiological adaptation profiles, and that both more complex strategies showed a more favorable biological profile than UNI.
Perineal urethrostomy (PU) involves the creation of a urethral meatus at the perineal level. Traditionally, it was regarded as a last-resort therapeutic option or the outcome of failed previous reconstructive attempts. Currently, this perspective has evolved, and PU is increasingly considered a primary indication in complex cases or in patients with significant comorbidities. PU can be performed either as a definitive procedure-in patients with extensive, recurrent strictures or in those with comorbidities that preclude formal reconstruction-or as a temporary measure to facilitate healing and optimize conditions prior to definitive reconstructive surgery. In oncologic cases associated with total penectomy, PU serves as the definitive form of urinary diversion, and the same reconstructive principles should be applied to its design. A key requirement for PU is preserved sphincteric continence and the absence of proximal urethral stenosis. Advances in surgical techniques, including the use of flap mobilization and grafting, have enabled the creation of wide, functional meatuses, reducing the rate of stricture recurrence. Additionally, non-transecting variants aim to preserve the vascularization of the dorsal urethral surface. Following these surgical principles, high success rates can be achieved. Despite representing a significant alteration of anatomy and voiding habits, patient satisfaction is generally high. PU should not be viewed merely as a palliative alternative but rather as a versatile reconstructive option capable of providing comfortable and durable voiding in selected patients. Appropriate patient selection and meticulous surgical execution remain essential pillars of contemporary urethral surgery.
E-cigarettes pose health risks and no established benefits to people who have never used tobacco. Australia introduced legislation in 2021, which was strengthened in 2024, to limit e-cigarette sales to pharmacists among other restrictions. This study explored the impact of these reforms. Weighted data from serial cross-sectional annual population-representative surveys (Health Omnibus Survey (2014-2017) and Population Health Survey Module System (2018-2024)) of South Australians aged 15 years and older (n=32 737) were used to assess e-cigarette use and cessation attempts overall by tobacco use status and demographic characteristics. The prevalence of current e-cigarette use was steady between 2014 (1.2%, 95% CI 0.7% to 1.8%) and 2020 (2.6%, 95% CI 1.7% to 3.5%), then doubled to 6.1% in 2023 (95% CI 4.6% to 7.7%) before declining in 2024 to 4.2% (95% CI 3.4% to 5.1%). Changes were most pronounced among those aged 15-29 years, where the prevalence of e-cigarette use and having never used tobacco rose 12-fold from 1.4% (95% CI 0 to 3.3%) in 2020 to 17.0% (95% CI 8.8% to 25.3%) in 2023, before declining to 5.5% (95% CI 3.3% to 7.7%) in 2024. Half of participants using e-cigarettes (49.3%) had ever attempted to quit vaping, though unprompted awareness of doctors or pharmacists as available sources of support was low (2.8%). Early results indicate that Australia's strengthened vaping reforms correspond with reductions in e-cigarette prevalence in South Australia, driven mainly by declines among youth who have never used tobacco. Continued monitoring is needed to consolidate evidence of this public health gain alongside improved awareness of cessation support services.
To synthesise evidence from systematic reviews on difficult intravenous access (DIVA) in adults, focusing on definitions, diagnostic criteria, risk factors and clinical interventions to guide clinical practice and health policy. Umbrella review of systematic reviews and meta-analyses. Any clinical setting involving adult patients requiring peripheral venous access (including hospital, emergency and outpatient care). A systematic search was performed in PubMed, CINAHL, Cochrane, Scopus and Web of Science in July 2025. Systematic reviews and meta-analyses published from 2014 to 2025 that addressed DIVA in the adult population were included. Primary studies and protocols were excluded. Methodological quality was assessed using the Risk Of Bias In Systematic Reviews tool. Data extraction followed the Joanna Briggs Institute methodology for overviews and the Preferred Reporting Items for Overviews of Reviews reporting guideline. Seven reviews (six systematic reviews and one meta-analysis) were included. Three analytical dimensions emerged: (1) the conceptual and operational definition of DIVA, identifying common elements such as ≥2 failed attempts, lack of visible or palpable veins and a documented history of difficult access; (2) risk factors and clinical assessment, highlighting obesity, chronic diseases, prior chemotherapy, venous invisibility or non-palpability and the limited validation of diagnostic tools and (3) interventions, including organisational strategies (escalation protocols, specialised teams), technological resources (ultrasound guidance) and clinical measures (pain management and technique optimisation). DIVA is a multifactorial challenge that requires a standardised definition to improve clinical identification. Effective management relies on a combination of specialised training, the use of ultrasound technology and the implementation of escalation protocols to ensure patient safety and efficiency. CRD420251084947.
The objectives of this study were: (1) to identify factors influencing the performance of dairy cows in an automated milking system (AMS); (2) to construct a synthetic robotic adaptability index (RAI) of cows' adaptation to the AMS; (3) to evaluate the predictive capabilities of traits describing the milking process and RAI; and (4) to compare the predictive power of different modeling approaches. The data on 796 primiparous Polish Holstein-Friesian cows (40,233 milkings) were obtained from the milking robot management system. Milking efficiency (ME), and the average number (AA) and time (AT) of the teat cup attachments and RAI served as predicted variables. Days in milk, and four AMS milking-related and 18 linear conformation traits were used as predictors. The highest predictive ability for ME was achieved with multilayer perceptron (R2 = 0.895), followed by linear regression. For AA, AT, and RAI, the highest R2 values were obtained for LASSO regression (0.663, 0.642 and 0.670, respectively). The key factors determining milking performance were functional variables, particularly milk flow rate (MilkFlow) and the number of failed milking attempts (Failure), while conformation traits had limited significance. More complex machine learning models do not always lead to improved prediction quality compared to statistical methods, which emphasizes the need for a critical approach to their application in the analysis of production data.
Unanticipated difficult airway management remains a major contributor to perioperative morbidity and mortality. Conventional bedside tests have shown limited and variable predictive accuracy, and no single test reliably identifies patients at risk. Point-of-care airway ultrasonography has emerged as a promising adjunct, but the diagnostic performance of specific sonographic parameters - particularly the skin-to-epiglottis distance (SED) - requires further evaluation. In this prospective, single-center observational study, 400 adults (18-70 years; ASA I-III) scheduled for elective surgery under general anesthesia with orotracheal intubation were enrolled. Before induction, the attending anesthesiologist performed a standardized bedside assessment (modified Mallampati classification, upper lip bite test, and thyromental, sternomental, interincisor, and mentohyoid distances). A second anesthesiologist experienced in airway ultrasonography, blinded to the bedside findings and intraoperative outcomes, obtained sonographic measurements including SED, skin-to-thyroid cartilage and thyroid cartilage-to-epiglottis distances, pre-epiglottic space depth, tongue thickness, and hyomental distance in neutral and extended positions. The prespecified primary outcome was difficult intubation (two or more intubation attempts); difficult mask ventilation (DMV; requiring two-handed two-provider technique or airway adjuncts) was the prespecified secondary outcome. Between-group comparisons and receiver operating characteristic (ROC) curve analysis were performed, with optimal cutoffs identified by the Youden index. Difficult intubation occurred in 20 patients (5.0%) and DMV in 27 (6.8%). Among bedside tests, the upper lip bite test and modified Mallampati classification were significantly associated with difficult intubation. SED yielded the highest point-estimate discrimination (AUC 0.912; 95% CI 0.811-1.000; optimal cutoff 2.14 cm; 85% sensitivity, 91% specificity); given the limited number of events, these estimates are subject to imprecision and should be interpreted as exploratory. Predictors of DMV followed a distinct pattern, dominated by demographic, comorbid, and broader anatomical factors rather than by any single ultrasound parameter. Preoperative airway ultrasonography - and in particular SED - provided supplementary anatomical information beyond conventional bedside assessment for difficult intubation, whereas predictors of difficult mask ventilation followed a distinct pattern, supporting the view that these are related but non-identical airway phenotypes. Given the single-center design and the limited number of events, these findings require external validation in multicenter studies incorporating multiparametric ultrasound-and-clinical models and contemporary videolaryngoscopy-based airway management. The study was retrospectively registered at ClinicalTrials.gov (NCT07383610; registered 26 January 2026) after study initiation. This timing is reported transparently and does not affect data integrity or the prespecified analyses.
Wearable technology has become popular today not only for clinical uses but also among the general public for everyday activities such as fitness tracking and activity recognition. It's no secret that wearable devices need to be more comfortable and that there is increasing attention to their reliability and accuracy. Therefore, researchers are making various attempts to improve these specifications. Recent research has employed multimodal fusion, rather than relying on results from a single source, such as electrocardiography (ECG) or photoplethysmography (PPG), because it enables a more comprehensive understanding of physical conditions. There are very few extensive reviews of ECG and PPG wearable multimodal fusion application systems, and they are limited to a single practical use. However, this review fills that gap and provides a comprehensive overview of recent wearable physiological monitoring technologies based on ECG and PPG, along with their modern multimodal fusion applications in the medical field. These include cuffless blood pressure estimation, stress monitoring, heart rate and heart rate variability monitoring. This presents the theoretical background, including the characteristics of ECG and PPG signals, recently developed wearable monitoring techniques for ECG and PPG, and the advantages and disadvantages of multimodal fusion. It also provides a comprehensive and comparative analysis of recent studies employing modern multimodal fusion approaches in the aforementioned medical field, as well as a discussion of the limitations and challenges of ECG-PPG wearable multimodal fusion systems reported in the literature. Therefore, this review will enable researchers to gain a complete and comprehensive understanding of the development of wearable multimodal fusion applications based on ECG and PPG.
Fasting during Ramadan has been found safe for most chronic kidney disease (CKD) patients, but may pose risks for some. The Ramadan and Kidney Disease (RaK) working group has developed a risk stratification tool to categorize CKD patients who intend to fast into low-, moderate-, and high-risk groups. We propose a Ramadan fasting calculator that incorporates key risk factors to guide fasting decisions for CKD patients. A prospective cohort study was conducted at Ambulatory Healthcare Services from March 2024 to August 2024. The Electronic Medical Records (EMRs) of 220 patients were reviewed, supplemented by telephone interviews conducted before and after Ramadan. The primary outcomes assessed were the Ramadan fasting experience and the occurrence of adverse significant events (ASEs), which include hospital admissions. Among the 220 participants, 71.4% completed all 30 days of fasting during Ramadan, 7.3% began fasting but had to break it, and 21.4% did not fast. This sample's mean and median RaK scores were 9.78 and 9.0, respectively; 55.5% had a score of 9 or lower, 24.5% had scores between 10 and 13, and 18.6% had scores above 13. A total of 39 adverse significant events (ASEs) were recorded. Using ordinal regression (proportional odds model) the RaK score was the only significant predictor of fasting (none, interrupted, complete), with an estimate of -0.159 (95% CI: -0.264 to -0.053), p = 0.003. The area under the curve (AUC) for predicting attempts at fasting (using logistic regression) was 0.715 (95% CI: 0.635-0.794), with an optimal cutoff of 9.5. Using logistic regression, a higher RaK score was significantly associated with an increased incidence of ASE (β = 0.253, OR = 1.287( 1.036-1.599, p = 0.023). Decision-curve analysis showed a positive net clinical benefit across threshold probabilities of 7-44%, identifying about 1 additional ASE patient per 10 evaluated patients and avoiding 1 unnecessary intervention per 7 patients compared with universal intervention at a 10% threshold. The RaK score demonstrated potential predictive value for fasting status and adverse events among CKD patients; however, validation in different populations is recommended.
Upstream migration of pancreatic duct (PD) stents is an uncommon adverse event and may be particularly challenging in the presence of variant ductal anatomy such as a meandering main PD (MPD). We describe an endoscopic approach using laser-assisted pancreatoscopy for the retrieval of an upstream-migrated PD stent. A 60-year-old woman with a previously placed 5F single-pigtail PD stent was found to have upstream migration into a meandering MPD, with the pigtail tip impacted in a side branch of the uncinate process. Multiple conventional endoscopic retrieval attempts were unsuccessful. Pancreatoscopy enabled direct visualization of the impacted stent. Before intraductal application, ex vivo trial laser cuts were performed on an identical polyether block amide pancreatic stent to assess laser/material interaction. Laser segmentation was subsequently performed intraductally under continuous saline irrigation using incremental energy settings. Stent fragments were successfully retrieved using pancreatoscopic forceps. Postprocedural pancreatoscopy demonstrated no ductal injury or ductal dehiscence. Laser-assisted pancreatoscopic segmentation facilitated safe endoscopic retrieval of an upstream-migrated pancreatic stent in complex ductal anatomy and may offer a minimally invasive alternative to surgery in select cases.
We describe the case of a previously healthy adolescent female who presented with chest discomfort and near-syncope, accompanied by trifascicular block and hypotension. Her clinical condition rapidly progressed to cardiogenic shock with neurological impairment. Despite multiple attempts, transvenous pacing failed to achieve consistent ventricular capture. Flecainide intoxication was subsequently confirmed through toxicological analysis. The patient was managed with invasive ventilation, veno-arterial extracorporeal membrane oxygenation (VA-ECMO), sodium bicarbonate and intravenous lipid emulsion therapy, resulting in full neurological and cardiac recovery following a prolonged intensive care unit stay. Flecainide overdose is rare but associated with high mortality due to profound conduction abnormalities and shock. Early recognition and timely escalation to advanced mechanical circulatory support, including VA-ECMO, are critical for survival.Learning points. Prompt identification and advanced haemodynamic support are lifesaving in severe flecainide intoxication, clinicians should consider VA-ECMO early in refractory cases.
The outcome of clinical islet transplantation has been influenced by various factors, including the volume of islet transplanted (IEQ), frequency of transplantation, islet size, and purity. Most studies have compared the outcomes with these factors individually. This review attempts to comprehend the key factors that influence the outcome of clinical islet transplantation by understanding and analyzing the relationship between them. The purity of the islet preparation is often overlooked, as it is often believed to have a higher level of purity associated with better clinical outcome. However, a recent study documented long-term outcome of transplantation is better when purity less than 50%. Various studies have documented the decrease in the proportion of small islets with an increase in purity. Poor clinical outcomes have been documented when the transplanted islet preparation contains a lower proportion of small islets. This is not only because small islets survive better with diffusion, but also the higher proportion of large islets is prone to producing overestimation in IEQ calculation, leading to inadequate transplantation volume. Vigorous purification processes may remove the potential stem cells or progenitor cells present in pancreas and lack the paracrine effect that supports the viability and function of transplanted islets.
Accurate endotracheal tube (ETT) size selection is vital in pediatric anesthesia, yet traditional age-based formulas such as the modified Cole's formula are often unreliable; ultrasonography (USG), by directly visualizing the subglottic airway, offers a more precise alternative. In a cross-sectional study of 75 children aged 1-8 years, elective cases underwent ultrasound measurement of the mean transverse subglottic diameter, while emergency cases relied on the age-based formula. Ultrasound demonstrated superior accuracy, reducing ETT changes (5% vs. 20%), second intubation attempts (5% vs. 20%) and post-intubation complications (4.5% vs. 16.5%). It also showed higher sensitivity (100% vs. 96%) for predicting appropriate tube size. Thus, we show ultrasonography as a more reliable method than traditional formulas and recommend its integration into routine pediatric airway assessment.
Referential communication experiments, in which participants negotiate meaning without conventional language, have provided insights into the origins of language and the modalities that accompanied its early forms. However, these experiments are resource-intensive, limiting sample sizes and the diversity of stimuli. This study provides an empirical validation of expressibility ratings - participants' subjective judgments about their ability to communicate concepts through different modalities - as an efficient alternative to laboratory-based production experiments. We collected expressibility ratings for 207 concepts across three modalities: gesture-only, vocalization-only, and combined gesture-vocalization. These ratings were empirically validated against a production experiment in which participants attempted to communicate 84 selected concepts. We measured communicative success using binary accuracy (correct/incorrect) and continuous semantic similarity between guesses and targets. Results strongly support the empirical validity of expressibility ratings. Higher expressibility ratings reliably predicted greater guessability (both measures) and required fewer corrective attempts when feedback was provided. Feedback improved exact matches but not semantic similarity. Modality comparisons revealed that gesture-only and combined modalities performed equivalently and both substantially better than vocalization-only. To further showcase the utility of the ratings, we created robust simulations to investigate potential bias in concept selection for stimuli. The analysis examined varying semantic domains and stimulus and participant numbers, finding no systematic bias toward gestural superiority, suggesting robust modality differences. The strong correspondence between expressibility ratings and actual communicative success demonstrates that humans have intuitions of their nonlinguistic communicative abilities. These findings establish expressibility ratings as a methodologically efficient tool for studying modality affordances, enabling larger-scale investigations with enhanced statistical power and broader conceptual coverage.
Much of the existing literature for wave energy converters focuses on devices tailored to grid-scale performance. In this paper, we present the development of TigerRAY, a small, blue-economy scale wave energy converter, designed to generate 100 W in fetch limited waves. This development process involved in-lab dynamometer testing, two years of drifting field tests, and a two month moored deployment on Lake Washington. Through this process, we show the impact of proper ballasting to TigerRAY's performance, and highlight the importance of dynamometer testing to PTO development and characterization. We also show that power electronics are critical not only to the power output of the device, but to the device dynamics as well. We demonstrate the feasibility of a wave energy converter hosting a dock for an uncrewed underwater vehicle in the field, successfully docking the vehicle with the wave energy converter in all six demonstration attempts. Finally, we provide analysis of data from field testing. TigerRAY's relationship between power output and significant wave height remains relatively constant through changing wave directions, float locations, and power electronics functionality.
A prominent symptom of post-acute sequelae of SARS-CoV-2 infection (i.e., Long COVID) is exercise intolerance with or without post-exertional malaise (PEM). PEM is characterized by the worsening of both symptoms and function following even minor physical or mental exertion, with symptoms typically worsening 12 to 48 hours after activity and lasting for days or even weeks. Individualized, supervised cardiopulmonary rehabilitation is considered a safe and effective intervention for many cardiac and pulmonary conditions, and has been effective in gradually improving function in previously hospitalized and nonhospitalized patients with severe COVID-19. While traditional cardiopulmonary rehabilitation approaches appear helpful in some situations, the exercise intolerance symptoms experienced by many individuals with Long COVID may require a different approach, especially when attempts to increase physical activity result in PEM. No clear consensus exists on the optimal treatment of PEM, and no major studies have evaluated the efficacy in individuals with Long COVID of either carefully supervised, individualized cardiopulmonary rehabilitation programs for exercise intolerance without significant PEM or activity pacing interventions designed to treat or prevent PEM. The Researching COVID to Enhance Recovery Clinical Trials (RECOVER-CT) initiative funded by the National Institutes of Health (NIH) included a prospective, multicenter, randomized controlled platform trial (RECOVER-ENERGIZE) designed to assess two interventions in patients with Long COVID and exercise intolerance: (1) cardiopulmonary rehabilitation for patients without significant PEM and (2) structured activity pacing to prevent or reduce PEM in participants who experience the symptom. The intervention duration will be 12 weeks. The primary endpoints for the trial include the Endurance Shuttle Walk Test as a measure of endurance capacity for the cardiopulmonary rehabilitation intervention and a modified version of the DePaul Symptom Questionnaire-Post-Exertional Malaise for the pacing intervention. Assessments will be completed at baseline, middle of intervention, end of intervention, and 12 weeks after completion of the intervention, and include physical performance measures and patient-reported surveys. The RECOVER-ENERGIZE trial protocol has been approved by an institutional review board (Advarra), and written informed consent will be obtained from all participants prior to enrollment. The trial is registered on ClinicalTrials.gov ( NCT06404047 ). Formally assessing PEM and developing a structured activity pacing intervention delivered by local pacing coaches are novel features of this trial. Results will be disseminated through peer-reviewed publications, presentations at scientific conferences, and communication with participants, patient advocacy organizations, and the broader Long COVID community. De-identified participant data will be made available through the NIH RECOVER data repository in accordance with NIH data-sharing policies. If successful, this protocol will provide accessible tools that clinicians can use to address exercise intolerance and PEM in patients with Long COVID. ClinicalTrials.gov - Platform: NCT06404047 ; Appendix A: NCT06404060 ; Appendix B: NCT06404073 . Registered on May 6, 2024. RECOVER-ENERGIZE is a large, multicenter, randomized controlled platform trial that stratifies participants by PEM status, separately evaluating cardiopulmonary rehabilitation in those without significant PEM and structured activity pacing in those with PEM, while mitigating the risk of exertional harm.The structured activity pacing intervention is novel and has not previously been tested in a randomized trial in Long COVID. Its coach-delivered, video-conference format is designed to be easily implemented and scalable across diverse clinical settings.Patient, caregiver, and community representatives were integrally involved throughout protocol development, shaping eligibility criteria, intervention design, and selection of outcome measures, which strengthens the relevance of the trial to the Long COVID community.The trial combines a performance-based measure of endurance capacity (the Endurance Shuttle Walk Test) with a modified, PEM-specific patient-reported instrument (mDSQ-PEM). However, the nature of the interventions precludes blinding of participants and providers, and several key outcomes rely on self-report, which may introduce bias.
To evaluate the introduction of locally configured standard concentration (StdC) intravenous drug infusions in critically ill children. This two-year quality improvement retrospective cohort study (2018-20) examined post-implementation of 47 StdC drugs configured across three weight bands: <5 kg, 5-20 kg and >20 kg in a 26-bed, multispecialty paediatric intensive care unit. The main outcome measures were (1) adherence to StdC use (non-adherence defined as using a bespoke drug concentration), (2) attempts at dosing above the pre-set infusion rates, known as hard limit events (HLEs), (3) incidents related to infusions and (4) percentage of total fluid allowance available for nutrition. In total, 33 224 infusions were administered, with morphine, clonidine and milrinone representing 61%. Most of them (83.6%) were initiated in children in the lower weight bands. Adherence to StdCs was 96% and was similar across weight bands. A total of 204 498 pump programming events were examined, with 418 (0.2%) being HLEs. Only 21 HLEs (0.01%) were considered potentially clinically significant (defined as programming >2.5 times the maximum dose). Following investigation, 20/21 were found likely to be related to training episodes, rather than true errors. Twenty clinical incidents linked to StdC infusions were reported but none caused harm. The mean fluid allowance available for nutrition after accounting for StdC volumes was 38.8% in the <5 kg weight band, and 71% and 67.4% in the other two bands, respectively. Configured StdCs are effective and safe across all weight bands and allow for partial provision of nutritional needs in fluid-restricted patients. The high adherence rate facilitated pharmacy supplying infusions as Ready-To-Administer (RTA).