Widening social, economic, and health inequities intensify the need for equity strategies in health care if population health is to be improved. EQUIP Health Care, a program of research and knowledge mobilization aimed at supporting health care organizations to promote equity, has been developing and testing organizational-level interventions. This process evaluation of the implementation of EQUIP Emergency, a collaboration among staff and leaders at three diverse Emergency Departments, community and Indigenous leaders, and researchers, provides direction to organizations wishing to promote health and health care equity. This process evaluation, grounded in the Active Implementation Frameworks, is based on analysis of qualitative comments from a staff survey (n = 313 comments), qualitative interviews with staff, leaders, and researchers (n = 43), and observational data captured as fieldnotes (n = 784 entries). A thematic analysis identified four themes pertaining to the process and implications of engaging with EQUIP Emergency. Despite a rhetorical and practical commitment to equity at all levels, other priorities, including ensuring staffing adequate to provide care, orienting new staff, and responding to escalating crises such as the unregulated drug poisoning emergency, violence in Emergency Departments, and later in the study, COVID-19, overshadowed efforts toward equity. The material (e.g. staffing) and non-material (e.g. skills) resources available to support and aligned with equity goals shaped the capacity of staff, leaders, and the organizations to enact equity goals. Our analysis led to 10 suggestions for leaders at all levels of health care, including clinical, executive, and policy leaders, for systematically cultivating equity in health care service settings. To promote equity, health care organizations must approach equity as foundational, not as an "add-on," link equity to key organizational issues, engage leaders from all relevant employment groups at the outset and throughout, engage and compensate staff at all levels and from all roles, and counter siloed bureaucracies (systemic structural misalignments) within their systems. Time for leaders to comprehensively plan should be augmented with analysis of local patient and staff data that can be shared with direct care providers to set the stage for implementing equity strategies and evaluating progress as an embedded way of doing business. Clinical Trials.gov #NCT03369678 (registration date November 18, 2017).
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).
Disparities in arrhythmia care are increasingly recognised, yet remain incompletely characterised across the patient pathway. This European Heart Rhythm Association (EHRA) survey explored clinician-reported perceptions of inequity across diagnosis, pharmacological management, procedural referral and follow-up. A 30-question survey was disseminated via the EHRA between November 2025 and January 2026, with 212 responses from professionals across 35 countries. Respondents were predominantly consultant electrophysiologists (67.5%), with 39.6% identifying as female. Most (68.4%) reported no prior training in equity or inclusive care. Across the arrhythmia care pathway, disparities were most frequently attributed to patient vulnerability, particularly cognitive impairment (72.5%), age >80 years (63.8%) and mental health disease (61.3%). Differences related to socioeconomic status, language and other social factors were also commonly reported. Female sex and minority ethnic background were each reported to influence care in 24.1% of responses. Age >80 years was consistently identified as the strongest determinant of disparities in referral, diagnosis and outcomes, influencing referral for arrhythmia evaluation (65.8%), catheter ablation (77.9%) and outcomes following ablation (68.1%). Socioeconomic and ethnic factors showed more modest but consistent effects, while sex-based differences were less frequently reported. However, female respondents were more likely than male respondents to report delayed referral (female respondents: 41.8%; male respondents: 19.8%) and late or incorrect diagnosis (49.4% vs 15.8%) in female patients, as well as delayed referral for catheter ablation (36.5% vs 10.3%) and device implantation (23.0% vs 7.0%). Only one-third of respondents (33.3%) felt that current international guidelines adequately address diversity, equity and inclusion in arrhythmia care. Clinicians perceive disparities in arrhythmia care across multiple patient and social factors. Whilst age and vulnerability were most frequently perceived to influence care, sex and ethnicity were also recognised by a substantial proportion of respondents. Perceptions varied according to respondent characteristics, with female clinicians more likely to report disparities amongst female patients. Limited training and institutional frameworks highlight opportunities for targeted interventions.
Self-reliance consists of using available resources, making informed decisions, and responsible health and lifestyle practices. The complex nature of healthcare practices by the people necessitates the quest for understanding self-reliance in primary healthcare. In LMICs, around 70% in India and approximately 80% in sub-Saharan African countries use traditional medicine for primary healthcare. Because of its emphasis on local resources, context, culture, and other determinants, traditional medicine potentially enables self-reliance in primary healthcare. The study explored the meaning of self-reliance in primary healthcare from peoples' perspective among families using traditional medicine in a Southern Indian site. We conducted case study research in HD Kote, a taluka in Mysore district of Karnataka in Southern India, from September 2021 to April 2022. We selected 30 study participants using purposive sampling and the data was collected through in-depth interviews. Data was subjected to thematic analysis using QDA Miner lite 2.01 version software. The study identified following themes: 1) perception of health and illness, 2) healthcare pathways, 3) negotiation between the environment and self in the emergence of self-reliance, and 4) efficiency and authenticity as a means to choose healthcare approach. Pathways to healthcare decisions were influenced by various cultural, social, religious, health system, and individual level factors. Self-reliance emerges from an individual through negotiation between the self, the environment, and the social context in which they live. The meaning of self-reliance was navigated within healthcare practices, choices, and the context in which an individual lived. Capturing people's perspectives and local views addresses the gap in scientific understanding by situating these perspectives within the broader context of the health system, particularly in relation to self-reliance and the role of individuals. Understanding self-reliance through studies of this kind is critical to contributing to a people-centered health system for India to achieve the goal of universal health coverage. La autosuficiencia consiste en utilizar los recursos disponibles, tomar decisiones informadas y mantener prácticas responsables de salud y estilo de vida. La naturaleza compleja de las prácticas de atención sanitaria de las personas exige profundizar en la comprensión de la autosuficiencia en la atención primaria de salud. En los países de ingresos bajos y medianos (LMIC, por sus siglas en inglés), alrededor del 70% de la población en India y aproximadamente el 80% en los países del África subsahariana utilizan la medicina tradicional como parte de la atención primaria de salud. Debido a su énfasis en los recursos locales, el contexto, la cultura y otros determinantes, la medicina tradicional tiene el potencial de fomentar la autosuficiencia en la atención primaria. Este estudio exploró el significado de la autosuficiencia en la atención primaria desde la perspectiva de las personas, entre familias que utilizan la medicina tradicional en una región del sur de la India. Se realizó una investigación de estudio de casos en HD Kote, un taluka (distrito) de Mysore, en Karnataka, al sur de la India, entre septiembre de 2021 y abril de 2022. Se seleccionaron 30 participantes mediante muestreo intencional, y los datos se recolectaron a través de entrevistas en profundidad. La información se analizó temáticamente utilizando el software QDA Miner Lite versión 2.01. El estudio identificó los siguientes temas: 1) percepción de la salud y la enfermedad, 2) trayectorias de atención sanitaria, 3) negociación entre el entorno y el yo en la aparición de la autosuficiencia, y 4) eficiencia y autenticidad como criterios para elegir el enfoque de atención sanitaria. Las trayectorias hacia las decisiones de atención en salud estuvieron influenciadas por diversos factores culturales, sociales, religiosos, del sistema de salud e individuales. La autosuficiencia surge de la persona a través de la negociación entre sí misma, su entorno y el contexto social en el que vive. El significado de la autosuficiencia se manifiesta dentro de las prácticas de atención en salud, las elecciones individuales y el contexto en que la persona habita. Captar las perspectivas y visiones locales de las personas permite abordar las brechas en la comprensión científica al situarlas dentro del contexto más amplio del sistema de salud, especialmente en relación con la autosuficiencia y el papel del individuo. Comprender la autosuficiencia a través de estudios de este tipo es fundamental para contribuir a un sistema de salud centrado en las personas y avanzar hacia el logro de la cobertura universal de salud en la India.
Prescribed safer supply provides people dependent on street-acquired opioids with pharmaceutical opioids to reduce overdose risk. Previous experience with the healthcare system - including opioid agonist treatment or high-dose opioids prescribed for pain - is common among people dependent on unregulated opioids, as are experiences of significant stigma when seeking care. Our objective was to examine previous healthcare experiences and how these differ from receiving care in safer supply programs. Using reflexive thematic methods, qualitative interviews and focus groups were conducted in 2022 with 38 clients and 10 staff members from two prescribed safer supply programs in different parts of Canada: in London, Ontario and Victoria, British Columbia. Thematic analysis was used to examine themes related to experiences with the healthcare system both prior to initiating safer supply, and following engagement in care in a safer supply program. Prior to safer supply, participants described three trajectories of medical abandonment: abrupt deprescribing of high-dose opioids despite significant medical complexity, punitive and inadequate opioid agonist treatment, and pervasive stigma in healthcare settings. These experiences left participants deeply mistrustful of healthcare providers and forced to source opioids from the unregulated drug supply. Safer supply programs facilitated re-engagement in care through environments of trust and respect, with provision of opioids as a crucial step toward addressing complex health conditions and achieving social stabilization. Safer supply programs meet a critical need for comprehensive substance use care, reducing overdose risk while supporting management of complex medical conditions and social stabilization. For people previously deprescribed from opioid medications, prescribed safer supply assists in repairing trust and facilitating broader healthcare engagement. Our results caution against punitive, surveillance-oriented practices within safer supply prescribing, as these risk replicating the medical abandonment that created the need for alternative care models in the first place.
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Childhood cancer survival and stage at diagnosis vary internationally. Here, we explore differences in child health surveillance and healthcare practices across countries participating in the International Benchmarking of Childhood Cancer Survival by Stage (BENCHISTA) collaboration-with a focus on timely cancer diagnosis. We conducted a scoping review of five databases (MEDLINE, Embase, SCOPUS, Web of Science, and ProQuest Central) for articles published in English or Spanish between 1 Jan 2012 and 15 Oct 2025, describing child health surveillance and acute care pathways, limited to the 29 countries involved in the BENCHISTA collaboration. Two reviewers independently screened abstracts; a third resolved conflicts. In parallel, a semi-structured questionnaire was distributed (to one general practitioner, one paediatrician) in 27 countries who contributed to the BENCHISTA database. We collected standardised information on national child health practices and validated against published national guidance. Of 2,963 articles screened, 33 were included. Three key themes emerged: (1) healthcare-seeking behaviour of families and their interaction with frontline professionals, (2) awareness of alarm symptoms by caregivers and clinicians, and (3) system-level and training-related factors affecting timely diagnosis. Studies highlighted challenges such as low symptom recognition, variation in paediatric training, and limited referral guidance. Questionnaire responses showed variation in the number of routine child health checks with physical examination for children < 5 years (median 10; range 2-21), paediatric training, and access to diagnostic tools.  There is substantial international variation in routine child health surveillance and acute illness assessment. These findings will inform interpretation of BENCHISTA data and may guide future strategies to support early cancer diagnosis. • Childhood cancer survival and stage at diagnosis vary internationally. • Early recognition of alarm symptoms is critical but often delayed due to system-level gaps. • This study combines a scoping literature review and clinician survey across 27 countries, identifying shared barriers to timely diagnosis. • It reveals variation in paediatric training of front-line healthcare practitioners, referral pathways, and child health surveillance practices, even among high-income countries.
Nutritional therapy is a key component of critical care management, yet optimal strategies remain debated due to the heterogeneity of ICU patients, dynamic metabolic alterations, and the profound influence of inflammation on nutrient utilisation. Evidence from recent trials has challenged traditional one-size-fits-all approaches, emphasising the need for individualised, phase-specific nutrition throughout the continuum of critical illness and recovery. This manuscript summarises current concepts and emerging evidence in nutrition therapy presented at the 39th Annual Conference of the German Society for Nutritional Medicine (DGEM). Experts reviewed and critically discussed inflammation-driven metabolic changes, personalised energy and protein prescriptions, micronutrient management, macronutrient adaptation, ketogenic strategies in neurocritical care and sepsis, and nutritional considerations in post-ICU syndrome and outpatient recovery. This overview does not claim to be exhaustive; interpretations of individual study results partly reflect the views of the experts. Together with the inclusion of newer therapeutic approaches, this is intended to stimulate discussion and, at the same time, provide a basis for further studies. Inflammation and high disease severity strongly influence nutritional responsiveness, with highly inflamed patients demonstrating reduced benefit and heightened risk of overfeeding. Personalised strategies, including indirect calorimetry, fat-free mass-based protein dosing, and metabolic biomarkers such as the urea-creatinine ratio, offer a rational framework for tailoring therapy. Micronutrient deficiencies are common due to redistribution, pre-existing deficits, and extracorporeal losses, necessitating structured assessment and supplementation. Macronutrient delivery should be progressively escalated and regarded as a pharmacologic intervention aligned with disease phase and organ function. Early standardised ketogenic diet protocols show feasibility and potential clinical benefit in refractory status epilepticus and sepsis. Post-ICU and outpatient phases remain nutritionally vulnerable, with persistent catabolism and underfeeding common; structured, multidisciplinary rehabilitation and transitional nutrition programs may improve long-term outcomes. Future personalised nutrition strategies may rely on metabolic phenotyping and biomarker-informed stratification rather than uniform protein, energy and micronutrient targets for all ICU patients. Integrating individualised energy and protein prescription, targeted micronutrient management, emerging metabolic therapies, and coordinated post-ICU rehabilitation may optimise recovery and functional outcomes. Robust clinical trials are needed to confirm the impact of these personalised strategies on long-term patient-centred endpoints.
Routine assessment of gastric residual volume (GRV) to guide enteral feeding in critically ill children is widespread but not based on evidence. Perceived high gastric volumes often lead to withholding feeds, impairing nutritional delivery. To evaluate the effect of not routinely assessing GRV compared with assessments at least every 6 hours in children undergoing mechanical ventilation on the duration of mechanical ventilation and survival and achievement of nutritional targets. A pragmatic, multicenter, randomized, noninferiority trial in 23 pediatric intensive care units (PICUs) in the UK and 1 in Switzerland. A total of 4700 children aged 0 to 16 years who were receiving invasive ventilation and starting enteral feeds were recruited between June 29, 2023, and December 7, 2025, with 30-day follow-up completed on January 6, 2026. Children were randomized (1:1) to receive usual care (GRV assessment every 6 hours) or no routine GRV assessment to guide enteral feeding. In the no routine GRV assessment group, feed tolerance was assessed using only clinical signs. All other enteral feeding practices followed local protocols. The clinical co-primary outcome (noninferiority) was a composite of survival and days free from mechanical ventilation at 30 days. The nutritional co-primary outcome (superiority) was the percentage of children meeting energy requirements by 72 hours. Of the 4700 children randomized (2352 to the no routine GRV assessment group and 2348 to the usual care group), 4460 were included in the intention-to-treat analysis (median [IQR] age, 8 [1-44] months; 1925 [42.6%] females). No routine GRV assessment was noninferior to regular 6-hourly assessments for survival and days free from mechanical ventilation at 30 days (median [IQR], 25 [21-27] days in both groups; adjusted odds ratio [OR], 0.95 [95% CI, 0.86-1.05]). Results of the per-protocol analysis were consistent with the intention-to-treat analysis (adjusted OR, 1.01 [95% CI, 0.90-1.13]). The mean percentage of energy requirements achieved by 72 hours was 80.3% in the no routine GRV assessment group and 76.8% in the usual care group (adjusted mean difference, 3.2 [95% CI, 1.3-5.2] percentage points; P < .001). Among critically ill children being enterally fed, not assessing GRV routinely was noninferior to regular assessments every 6 hours and significantly increased nutritional achievement at 72 hours. isrctn.org Identifier: ISRCTN79668198.
Sex differences in intensive care treatment and mortality are well documented, but the timing of decisions to limit treatment remains unclear. We investigated whether sex differences in decisions to limit treatment arise at ICU admission or during the ICU stay. Nationwide cohort study using the Swiss Minimal Dataset for Intensive Care Units, including adult (≥ 18 years) ICU admissions between 2016 and 2024. Two adjusted logistic regression models assessed treatment limitations documented at ICU admission and those occurring later among patients admitted without limitations. Among 654,660 ICU stays, treatment limitations at admission were more common in women than men (12.0% vs. 8.6%), whereas rates during the ICU stay were similar (5.5% vs. 5.5%). Female sex was independently associated with limitations at admission (aOR 1.26, 95% CI 1.24-1.28) but only weakly associated with later limitations (aOR 1.10, 95% CI 1.08-1.13). Differences at admission varied by diagnosis and were most pronounced in trauma and cardiovascular conditions. Women more often had ceiling-of-care decisions and documented patient wishes, whereas men more frequently underwent withdrawal of life-sustaining therapies and physician-driven decisions. Mortality was highest with limitations at ICU admission and lowest without limitations, with minimal sex differences within categories. In Switzerland, sex differences in treatment limitations occur mainly at ICU admission and vary across diagnoses. These findings suggest that differences may reflect early triage heuristics, societal norms influencing advance care planning, and potential implicit biases under prognostic uncertainty. Structured goal-of-care discussions at ICU admission may help promote consistent and equitable decision-making.
Delirium is an acute encephalopathic syndrome that is highly prevalent in critically ill adult patients. The occurrence of delirium carries serious negative implications for patient outcomes and is a frightening and distressing experience for patients. The significance of delirium occurrence as an indicator of acute illness severity and clinical deterioration is well recognised. This is reflected in the inclusion of altered mental status in a number of national illness severity scoring systems. An awareness and understanding of delirium in the critically ill adult is therefore of relevance to all adult nurses. This article provides an overview of delirium in the critically ill adult patient, discussing current knowledge and recommended practice across key areas. These include the definition and classification of delirium; the implications of delirium for patient outcomes and experience; the aetiology and pathophysiology of delirium; delirium assessment tools used with critically ill patients and recommended approaches to prevention and management. The article will enable practitioners to develop a current understanding of key areas relating to delirium in the critically ill adult patient and encourage a reflective approach to considering the implications for practice.
Acute kidney injury (AKI) is a common and serious complication after cardiac arrest, affecting more than 30% of initially successfully resuscitated patients, with around 10% receiving Kidney Replacement Therapy (KRT). Currently, treatment options to prevent renal complications are limited. In this predefined sub-study of the Sedation, TEmperature and Pressure after Cardiac Arrest and REsuscitation (STEPCARE) trial, we evaluate the effects of sedation depth, fever management strategies, and mean arterial pressure (MAP) targets on the risk of major adverse kidney events (MAKE) in post-cardiac arrest patients. STEPCARE-MAKE is a predefined prospective sub-study of the international, randomized clinical STEPCARE trial. The main trial will enroll 3500 patients and employs a 2 × 2 × 2 factorial design, randomizing participants across three interventions: (1) deep sedation for 36 h or minimal sedation, (2) fever management with or without a feedback-controlled device, and (3) MAP target ≥ 65 mmHg or ≥ 85 mmHg. The primary outcome is the composite outcome MAKE, which includes death from any cause by day 30, initiation of KRT, or persistent renal dysfunction, defined as the final creatinine value ≥ 200% of the baseline at the time of discharge from the primary hospital or at day 30, whichever occurs first. Differences between baseline and the highest in-hospital creatinine, baseline and the last measured in-hospital creatinine, baseline and 72-h creatinine, and baseline and the highest creatinine within 72 h will be reported as secondary outcomes. The findings of this sub-study will provide new evidence on the renal effects of the STEPCARE trial interventions and may inform the future of individualized kidney-protective treatment approaches.
Critical illness often causes prolonged weakness, possibly due to impaired skeletal muscle regeneration, but the timing and nature of satellite cell (SC) dysfunction remain unclear. We aimed to determine whether SC depletion and dysfunction are detectable early after intensive care unit admission and describe their pathophysiological nature. In this prospective single-centre observational cohort study, mechanically ventilated adults underwent paired vastus lateralis biopsies within 72 h of ICU admission and again after 7 and 180 days. Isolated satellite cells were studied for proliferation, differentiation and fusion, mitochondrial morphology, respiratory function, substrate oxidation, and selected signalling proteins. We enrolled 20 healthy control subjects and 33 ICU patients. Twenty three ICU patients survived to day 7 with a repeat biopsy. During 7 days in ICU, the patient developed profound weakness (MRC score 16 [0-32]) and insulin resistance (whole body glucose disposal 4.0 [3.5-5.1] versus 13.8 [8.8-16.1] mg/kg/min in controls). Satellite cell number per fibre was similar in controls and patients at admission (0.106 [0.085-0.129] vs. 0.098 [0.056-0.125]) and after 7 days (0.084 [0.066-0.117]; paired p = 0.784). SC proliferation was lower in older patients (ρ=-0.68 and - 0.49) and associated with lower muscle strength (ρ = 0.55 and 0.62). Myogenic differentiation was transiently impaired at day 0 (fusion index 68.9% [66.3-71.7] vs. 74.0% [70.3-77.1] in controls; p = 0.029). Satellite cell bioenergetics and substrate preferences were broadly preserved. In contrast, a more fragmented mitochondrial phenotype was associated with lower proliferation, lower respiratory performance, and worse muscle strength (ρ≈-0.6 to -0.8), whereas more interconnected morphology was associated with better function (ρ ≈ 0.6-0.7). Out of 10 ICU survivors at day 180, only 7 attended follow up. In those, impaired SF-36 physical score (62.5 [55.0 to 75.0]) and SC proliferation capacity (~50 %), contrasted with improved insulin sensitivity and SC number per fiber (~71 % and ~95% of control values, respectively). Critical illness was associated with disturbed satellite cell regenerative programming and altered mitochondrial remodelling rather than early depletion of the satellite cell pool or overt bioenergetic failure. Age was a stronger predictor of early satellite cell dysfunction than disease severity. ClinicalTrials.gov, NCT05671614. Registered 4 January 2023.
The international Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend the implementation of a kidney protection strategy (KPS) in patients at high risk of and with Acute Kidney Injury (AKI). However, real-world implementation of this strategy in critically ill patients with AKI is unclear. We quantified timely and sustained adherence to KPS in critically ill adults with moderate-to-severe (KDIGO stage 2 or 3) AKI and explored associations with clinical outcomes. This was a multicenter, prospective cohort study enrolling adult patients with moderate or severe AKI requiring vasopressors and/or mechanical ventilation across five centers in Europe. The primary endpoint was adherence to the KPS, which included hemodynamic monitoring, sustained optimization of mean arterial pressure (MAP) > 65 mmHg, monitoring of serum creatinine and urine output, and avoidance of hyperglycemia, radiocontrast agents and nephrotoxins when possible, within 12 h after AKI diagnosis for 48 h or until ICU discharge. Exploratory analyses examined associations between adherence and renal outcomes. A total of 258 patients were enrolled (median age 69 years [IQR 62-75]; 65% male; median SOFA 10 [IQR 8-13]). The complete KPS was implemented in 80 patients (31%; 95% CI, 25.5-37.2%). Adherence to individual components of the KPS varied widely with optimization of MAP showing the lowest implementation rate (33%). In exploratory analyses accounting for death as a competing risk, KPS adherence was associated with a lower incidence of AKD beyond day 7 (subdistribution hazard ratio [SHR] 0.64; 95% CI, 0.41-0.99; p = 0.046), a higher incidence of renal recovery at hospital discharge (SHR 6.02; 95% CI, 4.00-9.05; p < 0.0001), and a lower incidence of RRT within 30 days (SHR 0.12; 95% CI, 0.02-0.91; p = 0.04). After multivariable adjustment, the association with renal recovery remained robust (adjusted SHR 6.29; 95% CI, 3.08-12.85; p < 0.0001). A clear dose-response relationship was observed between the number of implemented KPS components and renal outcomes. In critically ill patients with moderate-to-severe AKI, the complete KDIGO-recommended kidney protection strategy was implemented in approximately one-third of patients, and full KPS adherence was associated with a higher rate of renal recovery at hospital discharge.
Out-of-hospital cardiac arrest (OHCA) is a time-critical emergency in which ambulance clinicians must rapidly decide whether to initiate resuscitation. In the UK, up to 30% of OHCA patients also have a documented do not attempt cardiopulmonary resuscitation (DNACPR) decision. Despite these advance care plans, patients may still receive cardiopulmonary resuscitation (CPR), potentially causing distress to patients, relatives and clinicians, and increasing resource use. The frequency and predictors of such events in UK ambulance services remain poorly described. A retrospective service evaluation was undertaken using one regional ambulance service's OHCA registry (January-December 2024). Adults with a valid DNACPR or recommended summary plan for emergency care and treatment (ReSPECT) recommending against CPR, which was available to crews either electronically or physically at the time of the incident (or crews were informed by another HCP of the presence of a valid form), who suffered an OHCA and were attended by a regional emergency medical services (EMS) were included. The primary outcome was the commencement of any resuscitation attempt, defined as either over-the-phone CPR instructions or on-scene clinical intervention. Descriptive statistics compared cases with and without resuscitation. Univariable and multivariable logistic regression identified factors associated with a resuscitation attempt. Between 1 January and 31 December 2024 there were 7809 OHCAs, of which 1827 patients had a DNACPR; resuscitation by the ambulance service or bystanders occurred in 377 (20%) cases. Call handlers initiated most attempts (87%), and 36% received on-scene interventions. Median age was 80 years (IQR 70-90), and 51% were female. Multivariable analysis showed that each additional clinician on scene was associated with increased odds of resuscitation by 69% (adjusted odds ratio [aOR] 1.69, 95% CI 1.55-1.84; p <0.001). A public location carried a six-fold higher likelihood of resuscitation compared with assisted-living or nursing homes (aOR 6.08, 95% CI 1.47-27.4; p = 0.013). Home OHCAs were common and associated with a resuscitation attempt (aOR 1.41, 95% CI 1.00-2.01). Where dedicated end-of-life care single points of access were available in an area, there were lower odds of a resuscitation attempt (aOR 0.32, 95% CI 0.12-0.81). Patient age, sex and response time were not independent predictors of the outcome. One in five patients with a recorded DNACPR received a resuscitation attempt. This likely reflects the real-world complexities of DNACPR recognition in time-critical emergencies, including delayed access to documentation and potentially reversible presentations. Larger on-scene teams and public locations were associated with resuscitation, whereas a dedicated end-of-life care hub was associated with reduced attempts. Improving real-time visibility of advance care plans and strengthening end-of-life care pathways may help to ensure that care remains aligned with patient preferences.
Extracorporeal life support provides temporary cardiorespiratory support for patients with severe, potentially reversible cardiac and/or respiratory failure refractory to conventional measures. Its application has broadened across a wide spectrum of critical illness, yet the mechanistic basis of its physiological benefit remains incompletely defined.This review explores the mechanisms through which extracorporeal life support may confer benefit in respiratory and cardiac failure. These include restoration of gas exchange, optimization of circulatory dynamics, and mitigation of secondary organ injuries, creating conditions that facilitate tissue repair, enable adjunctive therapies, and in selected cases, provide a bridge to transplantation. In isolated respiratory failure, respiratory extracorporeal life support stabilizes gas exchange and modulates respiratory drive, enabling lung-protective ventilation and potentially attenuating ventilator- and patient self-inflicted lung injury. In cardiogenic shock, cardiac extracorporeal life support restores systemic perfusion and may reduce myocardial oxygen demand, while during cardiac arrest it may confer neuro-protective effects. In combined cardiorespiratory failure, advanced extracorporeal support modalities may augment both systemic and pulmonary circulation, supporting gas exchange and maintaining end-organ perfusion. Mechanistically, these interventions interrupt the cascade of hypoxemia- and/or hypercapnia- induced pulmonary vasoconstriction, right ventricular overload, and systemic hypoperfusion, facilitating multi-organ recovery. Optimizing patient selection, timing for extracorporeal life support initiation, and use of adjunctive therapies require a nuanced understanding of the interplay between these physiological pathways alongside careful considerations of key limitations including device-related complications, hematologic and inflammatory perturbations, and physiological trade-offs. This concise clinical review synthesizes the current literature on the mechanistic basis of extracorporeal life support in adults.
The understanding of acute kidney injury (AKI) has evolved, but it remains uncertain whether outcomes have improved over time. This study aimed to describe temporal changes in outcomes among intensive care unit (ICU) patients with AKI in Denmark from 2010 to 2024. This cohort study included adult patients with a first-time ICU admission, and AKI identified using creatinine changes in the seven days following ICU admission. The risks of chronic kidney disease (CKD), kidney failure (KF), and death were assessed one year after ICU admission across three periods: 2010-2014, 2015-2019, and 2020-2024. CKD was defined as an outpatient estimated glomerular filtration rate (eGFR) below 60 ml/min/1.73 m2 for more than 90 days. Similarly, KF was defined as an eGFR below 15 ml/min/1.73 m2, a hospital diagnosis, kidney transplantation, or initiation of chronic kidney replacement therapy. Follow-up was divided into seven to 89 days and from 90 to 365 days, and death was considered a competing risk for CKD and KF. A total of 48,529 patients with AKI were identified. The seven to 89-day mortality was 23.4% (95% confidence interval (CI): 22.5%-24.3%) in 2010-2014, compared to 22.3% (95% CI: 21.7%-22.9%) in 2015-2019, and 20.7% (95% CI: 20.2%-21.2%) in 2020-2024. The 90- to 365-day mortality was 10.3% (95% CI: 9.5%-11.0%) in 2010-2014, 10.2% (95% CI: 9.7%-10.7%) in 2015-2019, and 9.5% (95% CI: 9.1%-10.0%) in 2020-2024. The 90- to 365-day risk of CKD was 21.0% (95% CI: 19.9%-22.1%) in 2010-2014, compared to 19.8% (95% CI: 19.1%-20.6%) in 2015-2019 and 17.3% (95% CI: 16.7%-17.9%) in 2020-2024. The 90- to 365-day risk of KF was 2.2% (95% CI: 1.9%-2.6%) in 2010-2014, 2.1% (95% CI: 1.9%-2.3%) in 2015-2019, and 2.0% (95% CI: 1.8%-2.3%) in 2020-2024. In this cohort of ICU patients with AKI, mortality and risk of CKD decreased over time, while the risk of KF remained stable. These improvements are encouraging and may reflect changes in ICU management or post-AKI care, although the observational design precludes inference about underlying mechanisms.
Low anterior resection syndrome (LARS) is a common and often under-recognised consequence of sphincter-preserving rectal cancer surgery, encompassing a range of bowel symptoms including urgency, faecal incontinence, increased stool frequency, clustering and incomplete emptying. These symptoms can profoundly affect quality of life, dignity, emotional wellbeing and social participation, and may persist for years as part of long-term cancer survivorship. Transanal irrigation (TAI) is one evidence-based management option for patients with problematic LARS. Recent systematic reviews and randomised controlled trials suggest that it can significantly reduce LARS symptom scores and improve bowel predictability, with benefits demonstrated at 3, 6 and 12 months. However, early discontinuation remains a concern, often linked to technical difficulties, unmet expectations or insufficient follow-up. For nurses, TAI represents a supported clinical intervention rather than a technical procedure alone. Effective nursing care requires structured pre-treatment assessment, individualised patient education, practical training, expectation setting and planned follow-up. Nurses are central to identifying appropriate patients, supporting adherence, troubleshooting common problems and recognising when onward referral is required. This article explores the pathophysiology and impact of LARS, reviews the evidence for TAI, and sets out the nursing assessment, education and support required to deliver safe and effective care. It also considers quality-of-life outcomes, safety considerations, and the implications for practice within a broader multidisciplinary survivorship pathway.
Fatigue is a common and disabling sequela among survivors of critical illness, yet its long-term trajectory and clinical correlates during recovery remain poorly understood, particularly its dynamic evolution over time and its relationship with physical and psychological domains of recovery. We conducted a prospective multicenter observational study embedded in a structured ICU follow-up program across six Italian hospitals. Outcomes were assessed during standardized in-person visits at 3, 6, 12, and 24 months after ICU discharge. Fatigue was assessed using the Fatigue Severity Scale (FSS; severe fatigue defined as FSS ≥36). Muscle strength and functional exercise capacity were evaluated using handgrip dynamometry and the six-minute walk test (6MWT), and psychological symptoms using the Hospital Anxiety and Depression Scale (HADS). Generalized linear mixed models (GLMM) with time-lagged variables were used to examine whether clinical measures at one visit were associated with severe fatigue at the subsequent visit, including prior fatigue status to account for preceding fatigue burden. A total of 1,912 ICU survivors attended at least one follow-up visit, of whom 976 patients (51%) experienced severe fatigue at least once. The prevalence of severe fatigue was 336/967 (34.7%) at 3 months, 628/1,522 (41.3%) at 6 months, 434/1,135 (38.2%) at 12 months, and 64/217 (29.5%) at 24 months. Persistent severe fatigue across multiple visits was observed in 655 patients (34.3%), and individual trajectories were heterogeneous over time. In GLMM with time-lagged variable, prior fatigue status (OR 3.00, 95% CI 1.31-6.84), lower functional exercise capacity on the 6MWT (OR 0.77, 95% CI 0.61-0.95), and symptoms of anxiety (OR 6.76, 95% CI 2.01-22.68) and depression (OR 17.8, 95% CI 4.16-76.47), all measured at the preceding visit, were associated with severe fatigue at the subsequent visit. Severe fatigue remained common up to 24 months after ICU discharge, with heterogeneous trajectories over time and persistent severe fatigue affecting approximately one-third of survivors. Prior fatigue status, lower functional exercise capacity, and psychological distress were associated with subsequent fatigue, supporting the value of multidimensional assessment of recovery within structured ICU follow-up programs.
Delirium is a common and serious complication in critically ill patients, and family-centered care has emerged as a promising non-pharmacological strategy. However, evidence on structured, nurse-led family participatory support (NFPS) intervention remains limited. To evaluate the effectiveness and safety of NFPS in critically ill adult patients. Adult patients admitted to intensive care units (ICU) from three tertiary hospitals in Gansu Province were allocated to either the NFPS group or a usual care group without family participation (non-NFPS). In the NFPS group, trained family members participated in care under the guidance of ICU nurses. The primary outcome was the incidence of delirium. After 1:1 propensity score matching, 365 patients were included in each group. The NFPS group demonstrated significant reductions in incidence of delirium [26.85% vs. 34.25%, p = 0.03]. Compared with the control group, the NFPS group also had significantly shorter hospital length of stay (HLOS) (25 [17-34] vs. 30 [22-38] days, P < 0.001), ICU-LOS (13 [7-17] vs. 14 [10-18] days, P < 0.001), duration of mechanical ventilation (10 [6-15] vs. 11 [8-17] days, P < 0.001) and lower hospitalization cost (193,931.99 [117,616.64-294,201.02] vs. 199,330.72 [138,636.05-300,993.88] CNY, P = 0.032). No significant differences were observed in 6-month mortality (6.03% vs. 7.67%, P = 0.380), 1-year mortality (9.32% vs. 11.51%, P = 0.330), ICU-acquired weakness (26.58% vs. 29.59%, P = 0.270), ICU-acquired infection (19.45% vs. 19.73%, P = 0.930), or adverse events (2.19% vs. 3.84%, P = 0.190). The NFPS significantly reduced the incidence of delirium and was associated with shorter durations of mechanical ventilation, ICU-LOS, HLOS, lower hospitalization costs, without increasing the risks of ICU-AW, ICU-acquired infection, or adverse events. No significant differences were observed in long-term mortality between the two groups.